System and method for lung-volume-gated x-ray imaging

ABSTRACT

A system obtains multiple x-ray measurements corresponding to different breathing phases of the lung by determining, based on a volumetric measurement of the patient&#39;s breathing, a breathing phase of the patient and gating an x-ray imaging apparatus to produce an x-ray projection of the patient&#39;s lung when the breathing phase matched any of a plurality of different breathing phases. The system extracts multiple displacement fields of lung tissue from the multiple x-ray measurements corresponding to different breathing. Each displacement field represents movement of the lung tissue from a first breathing phase to a second breathing phase and each breathing phase has a corresponding set of biometric parameters. The system calculates one or more biophysical parameters of a biophysical model of the lung using the multiple displacement fields of the lung tissue between different breathing phases of the lung and the corresponding sets of biometric parameters.

CROSS-REFERENCE TO RELATED APPLICATIONS

This application is a continuation of U.S. patent application Ser. No.16/420,030, now U.S. Pat. No. 10,650,585, filed May 22, 2019, whichclaims priority to U.S. Provisional Patent Application No. 62/682,720,filed Jun. 8, 2018 and U.S. Provisional Patent Application No.62/812,818, filed Mar. 1, 2019, each of which is incorporated byreference in its entirety.

This application is also related to U.S. patent application Ser. No.16/420,007 filed May 22, 2019 and U.S. patent application Ser. No.16/420,011 filed May 22, 2019, each of which is incorporated byreference in its entirety.

TECHNICAL FIELD

Some embodiments of the present disclosure relate to medical imaging,and more particularly to systems and methods for performinggeometrically-resolved radiographic x-ray imaging. Some embodiments ofthe present disclosure relate to radiation therapy.

BACKGROUND

Computational modeling of human anatomy facilitates an understanding ofthe anatomical behavior that typifies different physiologicalconditions. While state-of-the-art imaging techniques can allow aphysician to visualize anatomic behavior, the state-of-the-arttechnology that accurately images the complex movement of the heart andlung is often too expensive to be widely adopted. Moreover, cardiacmotion, e.g., the deformation of the heart, which is an intricateprocess and unrelated to the breathing cycle, may appear as noise inCT-based or radiographic breathing motion measurements. Consequently,the accuracy of mathematical models that describe breathing motion willalso be degraded by seemingly random heart motion. One way of addressingthis issue is to remove lung motion from images by making patients holdtheir breath. While this approach stops the patient's breathing motion,crucial information on lung health may be hard to identify in thesebreath-hold images.

SUMMARY

Embodiments of the present disclosure seek to solve at least one of theproblems existing in the related art to at least some extent byproviding a geometrically-resolved radiographic x-ray imaging system(GREX).

According to some embodiments, a GREX imaging system acquires images ofa patient's chest by computationally targeting specific breathing phasesand a specific cardiac phase. By taking snapshots of the chest attargeted breathing phases in a series of imaging planes, the GREXimaging system obtains anatomic geometries that are independent of time.The time-independent anatomic geometries are co-registered andinterpolated, based on the collected breathing and cardiac signals, tocreate a volumetric interactive movie of the chest. The interactivemovie has key advantages over conventional static imaging. Using theinteractive movie, GREX creates biomechanical models that quantitativelydescribe how the chest geometry changes during patient respiration. Thebiomechanical models, based on fundamental physical laws, provideestimates of important quantities such as lung tissue elasticity,stress, strain, and respiratory compliance. These properties and othersprovide diagnostic capabilities that are currently unavailable tophysicians and practitioners in medicine. Physicians can leverage suchinformation provided by the GREX imaging system to inform on theetiology of the patient's lung disease.

In some embodiments, the GREX imaging system includes a unique hardwareand software add-on package for existing digital diagnostic x-ray units.Together, the hardware and software add-on package increase thediagnostic quality of a conventional digital diagnostic x-ray unit byproviding new and enhanced imaging capabilities through using thepatient's biometric signals to inform a custom imaging procedure thatgives more diagnostically informative information. The hardware andsoftware add-on package is a universal upgrade for any commerciallyavailable digital diagnostic x-ray unit (e.g., a legacy x-ray unit).

In accordance with some embodiments, a method of imaging a patient'slung is provided. The method comprises positioning the patient at afirst orientation relative to an x-ray imaging apparatus (e.g., an x-rayunit) and obtaining a volumetric measurement of the patient's breathing.The method includes, while the patient is positioned at the firstorientation relative to the x-ray imaging apparatus, and while obtainingthe volumetric measurement of the patient's breathing, determining,based on the volumetric measurement of the patient's breathing, abreathing phase of the patient. The method includes, in accordance witha determination that the breathing phase of the patient matches apredefined breathing phase, gating the x-ray imaging apparatus toproduce an x-ray projection of the patient's lung.

In some embodiments, the predefined breathing phase is a firstpredefined breathing phase of a plurality of predefined breathing phasesand the method further includes, while obtaining the volumetricmeasurement of the patient's breathing, in accordance with adetermination that the breathing phase of the patient matches any of theplurality of predefined breathing phases, gating the x-ray imagingapparatus to produce an x-ray projection of the patient's lung.

In some embodiments, x-ray measurements of the patient's lung are notobtained except when the breathing phase of the patient, as determinedby the volumetric measurement of the patient's breathing, matches one ofthe plurality of predefined breathing phases.

In some embodiments, the plurality of predefined breathing phasesincludes an early exhalation phase, a late exhalation phase, a maximumexhalation phase, an early inhalation phase, a late inhalation phase,and a maximum inhalation phase of a complete breathing cycle of thepatient.

In some embodiments, the x-ray projection is a first x-ray projectionand the method further includes repositioning the patient to a secondorientation relative to the x-ray imaging apparatus. In someembodiments, the method further includes, while the patient ispositioned at the second orientation relative to the x-ray imagingapparatus, and while continuing to obtain the volumetric measurement ofthe patient's breathing, continuing to determine, based on thevolumetric measurement of the patient's breathing, a breathing phase ofthe patient and, in accordance with a determination that the breathingphase of the patient matches the predefined breathing phase, gating thex-ray imaging apparatus to produce a second x-ray projection of thepatient's lung. In some embodiments, the method includes generating astatic image cube, corresponding to the predefined breathing phase,using the first x-ray projection and the second x-ray projection.

In some embodiments, the static image cube, corresponding to thepredefined breathing phase, is generated using less than ten x-rayprojections obtained from various angles at the predefined breathingphase.

In some embodiments, the volumetric measurement of the patient'sbreathing includes a measurement of the patient's chest rise.

In some embodiments, the volumetric measurement of the patient'sbreathing is obtained using one or more volumetric breathing phasesensors of the group consisting of: a three-dimensional (3D) scanner, aspirometer, and an abdominal belt.

In some embodiments, the method further includes creating a point cloudof a surface of the patient's chest. The volumetric measurement of thepatient's breathing is determined from the point cloud of the surface ofthe patient's chest.

In some embodiments, the point cloud of the surface of the patient'schest is obtained using a 3D imaging technique to measure one or morepositions of the patient's chest.

In some embodiments, the method further includes identifying one or moreanatomical landmarks on the surface of the patient's chest using thepoint cloud of the surface of the patient's chest and inferring alocation of one or more internal anatomical landmarks within thepatient's chest from the point cloud of the surface of the patient'schest.

In some embodiments, the breathing phase of the patient is a futurebreathing phase and determining, based on the volumetric measurement ofthe patient's breathing, a breathing phase of the patient includesforecasting the future breathing phase from one or more current and/orpast breathing phases.

In some embodiments, a method is provided. The method includespositioning a patient at a first orientation relative to a radiationsource, obtaining a measurement of the patient's breathing and obtaininga measurement of the patient's cardiac function. The method furtherincludes, while the patient is positioned at the first orientationrelative to the radiation source, and while obtaining the measurement ofthe patient's breathing, determining, from the measurement of thepatient's breathing, a breathing phase of the patient and determining,from the measurement of the patient's cardiac function, a cardiac phaseof the patient. The method further includes gating the radiation sourceto expose the patient to radiation based on a determination that thebreathing phase of the patient matches a predefined breathing phase anda determination that the cardiac phase of the patient matches apredefined window of the cardiac cycle.

In some embodiments, the radiation source is an x-ray imaging apparatusand gating the radiation source to expose the patient to radiationcomprises gating the x-ray imaging apparatus to produce an x-rayprojection of the patient's lung.

In some embodiments, the radiation source is a radiation therapy sourceand gating the radiation therapy source to expose the patient toradiation comprises gating the radiation therapy source to irradiate aregion of the patient's lung at a therapeutic dose.

In some embodiments, the method further includes, before gating theradiation source to expose the patient to radiation, obtainingmeasurements of the patient's cardiac function from a plurality ofcardiac cycles of the patient and, using the measurements of thepatient's cardiac function from the plurality of cardiac cycles,determining an average interval between a predefined cardiac phase and abeginning of the predefined window of the cardiac cycle. In someembodiments, determining that the cardiac phase of the patient matchesthe predefined window of the cardiac cycle includes predicting thepredefined window of the cardiac cycle by, in real-time, detecting thepredefined cardiac phase and waiting a length of time corresponding tothe average interval between the predefined cardiac phase and thebeginning of the predefined window of the cardiac cycle.

In some embodiments, the measurements from the plurality of cardiaccycles of the patient are waveform measurements of the plurality ofcardiac cycles and the method further includes validating, asstatistically stable, the waveform measurements of the plurality ofcardiac cycles.

In some embodiments, the predefined window of the cardiac cycle is aquiescent window of the cardiac cycle.

In some embodiments, a method of determining a biophysical model for alung of a patient from multiple x-ray measurements corresponding todifferent breathing phases of the lung is provided. The method includesextracting multiple displacement fields of lung tissue from the multiplex-ray measurements corresponding to different breathing phases of thelung. Each displacement field represents movement of the lung tissuefrom a first breathing phase to a second breathing phase and eachbreathing phase has a corresponding set of biometric parameters. Themethod further includes calculating one or more biophysical parametersof a biophysical model of the lung using the multiple displacementfields of the lung tissue between different breathing phases of the lungand the corresponding sets of biometric parameters.

In some embodiments, the one or more biophysical parameters define aphysical relationship between the biometric parameters associated withthe different breathing phases of the lung and the multiple displacementfields of the lung tissue.

In some embodiments, the physical relationship between the biometricparameters associated with the different breathing phases of the lungand the multiple displacement fields of the lung tissue is defined asfollows:

−

₀ =T _(V)

₁ +A _(f)(

₂+

₃)+H _(c)

₄

The

₁ vector describes normal stress caused by tidal volume,

₂ describes normal stress caused by airflow,

₃ describes shear stress caused by airflow, and

₄ describes tissue motion introduced by heart motion, and thedisplacement (

−

₀) of tissue at any point in a closed loop trajectory is expressed as asummation of the stress, strain, and perturbing heart motion vectorsscaled by the tidal volume (T_(v)), airflow (A_(f)), and cardiac phase(H_(c)) respectively.

In some embodiments, the method further includes generating multiplemedical image cubes corresponding to the different breathing phases ofthe lung from the multiple x-ray measurements corresponding to thedifferent breathing phases of the lung. The multiple displacement fieldsof lung tissue are extracted from the multiple medical image cubescorresponding to different breathing phases of the lung further bydelineating the lung tissue from a remaining portion of a first medicalimage cube through image segmentation. The method includes, for arespective voxel in the first medical image cube, determining adisplacement vector between the voxel in the first medical image cubeand a second medical image cube using intensity-based structure mappingbetween the first medical image cube and the second medical image cubeand iteratively refining the displacement vectors of different voxels inthe first medical image cube and their counterparts in the secondmedical image cube.

In some embodiments, the set of biometric parameters associated with arespective breathing phase includes a tidal volume and an airflow of thelung at the respective breathing phase and a cardiac phase correspondingto the respective breathing phase of the lung.

In some embodiments, the method further includes generating multiplemedical image cubes corresponding to different breathing phases of thelung from the multiple x-ray measurements corresponding to differentbreathing phases of the lung. In some embodiments, the method includeschoosing one or more of the multiple medical image cubes as referencemedical image cubes, determining a set of biometric parametersassociated with each reference medical image cube and selecting a set ofbiometric parameters based on biometric measurements of the lung betweentwo sets of biometric parameters associated with two reference medicalimage cubes. In some embodiments, the method further includes simulatinga medical image cube between the two reference medical image cubes byapplying the set of biometric parameters based on biometric measurementsof the lung to the biophysical model.

In some embodiments, the different breathing phases of the lung includeearly exhalation, late exhalation, maximum exhalation, early inhalation,late inhalation, and maximum inhalation of a complete breathing cycle ofthe patient.

In some embodiments, one or more sensors are used for measuringbiometric signals of the patient as one or more sequences of timeseries, including one or more of a 3D spatial position localizer, abreathing phase sensor, and a cardiac phase sensor.

In some embodiments, the 3D spatial position localizer is configured formeasuring the patient's real-time body movement caused by respirationand heartbeats and outputting them as time series.

In some embodiments, the breathing phase sensor is configured formeasuring one or more physiologic metrics related to the patient'sbreathing, including a tidal volume and its first-order time derivative.

In some embodiments, the cardiac phase sensor is configured formeasuring periodic and stationary electrical signals generated by thepatient's heart.

In some embodiments, the biometric signals of the patient measured bythe one or more sensors are used for triggering an x-ray unit to acquirean x-ray image of the patient at a specific breathing and cardiac phase.

In some embodiments, the x-ray unit includes a clock and the biometricsignals of the patient measured by the one or more sensors aresynchronized with the x-ray unit's clock. In some embodiments,respective values of the biometric signals are recorded to be associatedwith the acquired x-ray image.

In some embodiments, the biometric signals of the patient measuredduring a training window are used for building an optimized breathingprediction model for predicting a desired breathing phase at which anx-ray unit is triggered to capture an x-ray image of the patient.

In some embodiments, a method of generating a 3D x-ray image cube moviefrom 2D x-ray images of a patient is provided. The method includesconverting first multiple sets of x-ray images of a lung captured atdifferent projection angles into second multiple sets of x-ray images ofthe lung corresponding to different breathing phases. The method furtherincludes generating a static image cube from each set of the secondmultiple sets of x-ray images at a respective breathing phase using backprojection and combining the static image cubes corresponding to thedifferent breathing phases of the lung into a 3D x-ray image cube moviethrough temporal interpolation.

In some embodiments, the converting first multiple sets of x-ray imagesof a lung captured at different projection angles into second multiplesets of x-ray images of the lung corresponding to different breathingphases further comprises capturing the first multiple sets of x-rayimages of the lung at different projection angles. Each set of the firstmultiple sets of x-ray images corresponds to the different breathingphases of the lung at a particular projection angle. The convertingfurther comprises re-organizing the first multiple sets of x-ray imagesof the lung by their associated breathing phases into the secondmultiple sets of x-ray images of the lung. Each set of the secondmultiple sets of x-ray images corresponds to a respective breathingphase of the lung.

In some embodiments, the x-ray images within any particular set aregeometrically resolved and temporally independent.

In some embodiments, the different breathing phases of the lungcorrespond to different tidal volume percentiles of the lung's movement.

In some embodiments, the different breathing phases of the lung includeearly exhalation, late exhalation, maximum exhalation, early inhalation,late inhalation, and maximum inhalation of a complete breathing cycle ofthe patient.

In some embodiments, the multiple x-ray images of the lung captured atdifferent projection angles all correspond to the same breathing phase.

In some embodiments, one or more sensors are used for measuringbiometric signals of the patient as one or more sequences of timeseries, including one or more of a 3D spatial position localizer, abreathing phase sensor, and a cardiac phase sensor.

In some embodiments, the method further comprises identifying a cardiacphase gating window using one or more cardiac phase sensor measurements,predicting a breathing phase using one or more breathing phase sensormeasurements, identifying a coincidence between the cardiac phase gatingwindow and the predicted breathing phase for generating an x-ray imagingpulse, and tagging an x-ray image corresponding to the x-ray imagingpulse with the breathing phase, the cardiac phase, and 3D spatialposition localizer measurements.

In some embodiments, the 3D spatial position localizer is configured formeasuring the patient's real-time body movement caused by respirationand heartbeats and outputting them as time series.

In some embodiments, the breathing phase sensor is configured formeasuring one or more physiologic metrics related to the patient'sbreathing, including a tidal volume and its first-order time derivative.

In some embodiments, the cardiac phase sensor is configured formeasuring periodic and stationary electrical signal generated by thepatient's heart, with characteristic features that correspond to thecardiac phase.

In some embodiments, two distinct filters are used to remove signaldrift and noise from biometric signals of the patient after beingsynchronized with an x-ray unit's clock.

In some embodiments, the biometric signals of the patient measured bythe one or more sensors are used for triggering an x-ray unit to acquirean x-ray image of the patient at a specific breathing and cardiac phase.

In some embodiments, the x-ray unit includes a clock and the biometricsignals of the patient measured by the one or more sensors aresynchronized with the x-ray unit's clock. In some embodiments, therespective values of the biometric signals are recorded to be associatedwith the acquired x-ray image.

In some embodiments, the biometric signals of the patient are measuredduring a training window before capturing any x-ray image of the patientand the biometric signals of the patient measured during the trainingwindow include multiple complete breathing cycles of the patient.

In some embodiments, multiple tidal volume percentiles within a completebreathing cycle are identified using the biometric signals of thepatient measured during the training window, each tidal volumepercentile corresponding to one of the different breathing phases.

In some embodiments, the biometric signals of the patient measuredduring the training window are used for building an optimized breathingprediction model for predicting a desired breathing phase at which anx-ray unit is triggered to capture an x-ray image of the patient.

In some embodiments, the optimized breathing prediction model is basedon an autoregressive integrated moving average (ARIMA) model.

In some embodiments, the desired breathing phase for capturing the x-rayimage of the patient is configured to coincide with a cardiac gatingwindow during which heart induced lung motion is changing slowly.

In some embodiments, the cardiac gating window is chosen based onlocations of T wave and P wave in an electrocardiogram (ECG) signal suchthat the heart induced lung motion is changing slowly.

In some embodiments, the different breathing phases of the lung at aparticular projection angle are collected from at least two breathingcycles.

Additional aspects and advantages of embodiments of present disclosurewill be given in part in the following descriptions, become apparent inpart from the following descriptions, or be learned from the practice ofthe embodiments of the present disclosure.

BRIEF DESCRIPTION OF THE DRAWINGS

In order to describe embodiments of the present disclosure or technicalsolutions in the prior art more clearly, the drawings necessary in thedescriptions of the embodiments or the prior art will be brieflyexplained. Obviously, the drawings in the following description are justsome embodiments of the present disclosure. To those skilled in the art,in the premise of no creative labor, other drawings can also be obtainedaccording to structures illustrated in these drawings.

FIG. 1 is a schematic block diagram of the GREX imaging system includinga hardware box, acquisition software, and post-processing softwareaccording to some embodiments of the present disclosure.

FIG. 2 is a schematic flow chart of the GREX image acquisition processaccording to some embodiments of the present disclosure.

FIG. 3 is a schematic block diagram depicting a top-down view of a 3Dspatial position localizer of the GREX imaging system according to someembodiments of the present disclosure.

FIG. 4 depicts examples of two breaths sharing the same maximuminhalation phase in time but with radically different tidal volumesaccording to some embodiments of the present disclosure.

FIG. 5 depicts examples of tidal volume percentiles (two bottomsubplots) for a regular breathing patient (upper left subplot) and foran irregular breathing patient (upper right subplot), respectively,according to some embodiments of the present disclosure.

FIG. 6 is a schematic flow chart of a synchronization process accordingto some embodiments of the present disclosure.

FIG. 7 depicts a synchronized heart electrocardiogram (ECG) signal and alung breathing signal according to some embodiments of the presentdisclosure.

FIG. 8 is a schematic flow chart of a drift and signal noise removalprocess according to some embodiments of the present disclosure.

FIG. 9 depicts an exemplary breath plotted as tidal volume versus timeaccording to some embodiments of the present disclosure.

FIG. 10 depicts the same breath shown in FIG. 9 plotted as airflowversus tidal volume according to some embodiments of the presentdisclosure.

FIG. 11 is a schematic flow chart of a breathing phase predictionprocess according to some embodiments of the present disclosure.

FIG. 12 depicts an exemplary gating window in time chosen based on thelocations of T wave and P wave in the ECG signal such that the heartinduced lung motion is changing slowly according to some embodiments ofthe present disclosure.

FIG. 13 is a schematic flow chart of another GREX procedure usingcardiac phase prediction instead of real-time identification of acardiac gating window according to some embodiments of the presentdisclosure.

FIG. 14 depicts an example of triggered images, from left to right, atearly exhalation, late exhalation, maximum exhalation, early inhalation,late inhalation, maximum inhalation of a breathing phase according tosome embodiments of the present disclosure.

FIG. 15 is a schematic flow chart of an image acquisition triggeringprocess according to some embodiments of the present disclosure.

FIG. 16 is a schematic block diagram of variables used in an exemplaryGREX image reconstruction algorithm according to some embodiments of thepresent disclosure.

FIG. 17 is a schematic block diagram of operating components of the GREXimaging system during an imaging procedure according to some embodimentsof the present disclosure.

FIG. 18 is an exemplary depiction of the tissue depth a 0° (A) and 90°(B) x-ray projection traverse according to some embodiments of thepresent disclosure.

FIG. 19 is an exemplary depiction of depth resolution from a narrowprojection angle range (1) and a wide projection angle range (2)according to some embodiments of the present disclosure.

FIG. 20 is an exemplary illustration of the β imaging angle positionrelative to the three primary imaging planes (left) and relative to theimaging isocenter of the GREX imaging system in a top-down viewingorientation (right) according to some embodiments of the presentdisclosure.

FIGS. 21A-21B are an exemplary block diagram illustrating how the GREXimaging system transfers 2D x-ray projections into static image cubesand ultimately to an image cube movie according to some embodiments ofthe present disclosure.

FIG. 22 is a graphic depiction of the process of creating static imagecubes shown in FIGS. 21A-21B according to some embodiments of thepresent disclosure.

FIG. 23 is a schematic flow chart of an image filtering processaccording to some embodiments of the present disclosure.

FIG. 24 depicts an exemplary closed-loop lung tissue trajectory of apiece of tissue located in the left lung, close to the heart, caused bythe heart's interaction with the lung according to some embodiments ofthe present disclosure.

FIG. 25 is a schematic flow chart of operations of components of thebiomechanical model according to some embodiments of the presentdisclosure.

FIG. 26A is a graphic depiction of a lung tissue element's motiontrajectory during a breath cycle according to some embodiments of thepresent disclosure.

FIG. 26B is a graphic depiction of the displacement vectors betweendifferent breathing phases according to some embodiments of the presentdisclosure.

FIG. 27 is a schematic flow chart of a multi-resolution 3D optical flowalgorithm according to some embodiments of the present disclosure.

FIG. 28A is a schematic flow chart illustrative of creating a movie viabiometric interpolation according to some embodiments of the presentdisclosure.

FIG. 28B is a block diagram illustrative of creating interim image cubesusing the biometric data matrix according to some embodiments of thepresent disclosure.

FIG. 29 depicts an example of a healthy patient's standard radiographand a standard radiograph for a sick patient with a stage 1b left upperlung tumor (indicated with the arrow).

FIG. 30 depicts an example of GREX parameter maps showing indicators ofthe healthy patient's situation GREX parameter maps showing indicatorsof the sick patient's health situation according to some embodiments ofthe present disclosure.

FIGS. 31A-31B are flow diagrams for a method of imaging a patient's lungaccording to some embodiments of the present disclosure.

FIGS. 32A-32B are flow diagrams for a method of gating a radiationsource according to some embodiments of the present disclosure.

FIGS. 33A-33C are flow diagrams for a method of determining abiophysical model for a lung of a patient according to some embodimentsof the present disclosure.

FIGS. 34A-34C are flow diagrams for a method of generating a 3D x-rayimage cube movie according to some embodiments of the presentdisclosure.

FIG. 35 depicts an exemplary patient positioning fixture (PPF) (e.g., arotatable chair) for supporting a patient in accordance with someembodiments.

FIG. 36 depicts an exemplary biological event monitoring process (BEMP)card, in accordance with some embodiments.

DETAILED DESCRIPTION

Reference will be made in detail to embodiments of the presentdisclosure. The same or similar elements and the elements having same orsimilar functions are denoted by like reference numerals throughout thedescriptions. The embodiments described herein with reference todrawings are explanatory, illustrative, and used to generally understandthe present disclosure. The embodiments shall not be construed to limitthe present disclosure.

In the specification, unless specified or limited otherwise, relativeterms such as “central”, “longitudinal”, “lateral”, “front”, “rear”,“right”, “left”, “inner”, “outer”, “lower”, “upper”, “horizontal”,“vertical”, “above”, “below”, “up”, “top”, “bottom” as well asderivative thereof (e.g., “horizontally”, “downwardly”, “upwardly”,etc.) should be construed to refer to the orientation as then describedor as shown in the drawings under discussion. These relative terms arefor convenience of description and do not require that the presentdisclosure be constructed or operated in a particular orientation.

In the present invention, unless specified or limited otherwise, theterms “mounted,” “connected,” “coupled,” “fixed” and the like are usedbroadly, and may be, for example, fixed connections, detachableconnections, or integral connections; may also be mechanical orelectrical connections; may also be direct connections or indirectconnections via intervening structures; may also be inner communicationsof two elements, which can be understood by those skilled in the artaccording to specific situations.

In the present invention, unless specified or limited otherwise, astructure in which a first feature is “on” or “below” a second featuremay include an embodiment in which the first feature is in directcontact with the second feature, and may also include an embodiment inwhich the first feature and the second feature are not in direct contactwith each other, but are contacted via an additional feature formedtherebetween. Furthermore, a first feature “on,” “above,” or “on top of”a second feature may include an embodiment in which the first feature isright or obliquely “on,” “above,” or “on top of” the second feature, orjust means that the first feature is at a height higher than that of thesecond feature; while a first feature “below,” “under,” or “on bottomof” a second feature may include an embodiment in which the firstfeature is right or obliquely “below,” “under,” or “on bottom of” thesecond feature, or just means that the first feature is at a heightlower than that of the second feature.

FIG. 1 is a schematic block diagram of the GREX imaging system 100including a hardware box 102, acquisition software 104 (e.g., stored innon-transitory memory), and post-processing software 106 (e.g., storedin non-transitory memory) according to some embodiments of the presentdisclosure.

There are three measurement sensors in the hardware box 102 (e.g., 3Dspatial position localizer 300, breathing phase sensor 110, and heartphase sensor 112) that independently collect biometric signals of apatient as time series, and the collected time series serve as theinputs into the acquisition software 104. The acquisition software 104processes and filters the biometric time series measurements to generatean imaging trigger signal (e.g., that gets x-ray unit 108). The imagingtrigger signal targets a specific breathing phase and, optionally, acardiac phase of the patient. The breathing phase and cardiac phase areeach defined by their respective biometric time series measurements. Aconnector cable transmits the imaging trigger signal from theacquisition software 104 to the x-ray unit 108, which acquires breathingand cardiac phase radiographic images at the targeted phases. Onceacquired, a series of breathing and cardiac phase targeted images, whichdefine a complete breathing cycle, are input into the post-processingsoftware 106. The post-processing software builds a biomechanical modelof lung motion from the breathing and cardiac phase targeted images. Thebiomechanical model is then used to generate other diagnosis results inthe post-processing software. Although this application uses x-ray imageas an example, it would be apparent to those skilled in the art that theapproaches disclosed in this application can be adapted to be applied toother types of medical images with little (if any) effort. For example,the process of building the biomechanical model is not limited to theuse of x-ray images and can use other types of medical images (e.g.,CT-Scan, Mill, etc.).

FIG. 2 is a schematic flow chart of the GREX image acquisition process200 according to some embodiments of the present disclosure (e.g.,performed by acquisition software 104, FIG. 1). Specifically, theacquisition software 104 synchronizes and processes the time seriesmeasurements from the hardware box 102 in order to remove potentialsignal drift and noise. The acquisition software 104 then implements aphase prediction algorithm that predicts the breathing and cardiac phasefrom the synchronized, drift-free and noise-free time series inputs.Based on the breathing and cardiac phase prediction results, theacquisition software 104 uses a logic algorithm 118 to search fortargeted breathing and cardiac phase coincidences. The targetedbreathing and cardiac phase coincidences define the conditions thatprompt the image trigger generation and the resulting image acquisitionsby the x-ray unit 108. Once the GREX images are acquired, thepost-processing software performs new lung disease diagnosis using theGREX images that was previously unavailable to healthcare professionals.For example, the acquired GREX images are used to build a biomechanicalmodel that defines the chest geometry as a function of the breathing andcardiac phase without explicitly including a time parameter.

In this document, a GREX-based imaging system is divided into threesections. Section 1 describes embodiments of the hardware box 102.Section 2 describes embodiments of the acquisition software 104. Section3 describes embodiments of the post-processing software 106. Eachsection describes, in greater detail, the components and functions thatconstitute the hardware box 102, the acquisition software 104, and thepost-processing software 106 as shown in FIG. 1.

Section 1. Hardware Box 102

In some embodiments, the hardware box 102 has at least tworesponsibilities. The first is to collect biometric signals that definethe chest's anatomic geometry. The second is to communicate with thedigital diagnostic x-ray unit (e.g., x-ray unit 108).

The biometric signal inputs that define the chest's anatomic geometryinclude: the chest dimensions (measured via the 3D Spatial Localizer300, FIG. 3), the breathing phase (measured via the breathing phasesensor 110), and the cardiac phase (measured via the ECG monitor).Within the hardware box 102, the biometric signals are sampled inreal-time, at 100 Hz, in order to create time series curves for eachsignal input. The outputs of the hardware box 102, namely the timeseries curves, are then passed to the acquisition software.

FIG. 3 is a schematic block diagram depicting a top-down view of a 3Dspatial position localizer 300 of the GREX imaging system 100 accordingto some embodiments of the present disclosure.

Section 1.1—3D Spatial Position Localizer 300

The 3D spatial position localizer 300 measures the patient's real-timebody movement caused by respiration and heartbeats and outputs them as atime series in a coordinate space (e.g., Cartesian, polar, hyper, etc.).As shown in FIG. 3, the 3D spatial position localizer 300 includes threeseparate 3D cameras (e.g., cameras 302 a through 302 c) that are fixedto a balanced circular tract on the room's ceiling. There are 120°angular increments separating the system's three cameras 302 a from oneanother. The patient is located between the x-ray unit 108 and thedetector panel 304, such that the patient is located at the center ofthe ceiling-mounted 3D spatial position localizer 300. The systemmeasures the patient's chest expansion (e.g., rise and fall) in apredefined coordinate space. Each camera 302 has an unobstructed view ofthe patient's torso and one of the x-ray unit 108 and the detector panel304.

Using real-time depth maps, each 3D camera 302 creates a surfacerendering of the patient. Simultaneous information from all three 3Dcameras 302 is combined to form a volumetric skin surface positionmeasurement (e.g., using a ray-casting technique) that changes, inreal-time, based on the patient's breathing and cardiac phase. The 3Dspatial position localizer 300 uses the volumetric skin surface positionmeasurements in at least two ways: (i) defining the spatial boundary ofthe patient and (ii) determining the tissue location of the patient.Based on the assumptions such as skin thickness, rib thickness, muscularthickness, and skeletal position, which are derived from the canonicalMedical Internal Radiation Dose (MIRD) Anatomic Database, the 3D spatialposition localizer 300 approximates the lung's real-time, spatialposition inside the patient. The 3D spatial position localizer 300 usesthe MIRD data to calculate the lung's spatial boundary conditions, whichare then made available to the post-processing software 106. Forexample, the 3D spatial position localizer 300's estimation of thelung's spatial boundary condition creates an initial chest geometry thatthe post-processing software 106 uses to simulate the cumulative tissuedensity along a ray that originates at the x-ray unit 108.

Section 1.2—Breathing Phase Sensor 110

The breathing phase sensor 110 in the hardware box 102 measures keyphysiologic metrics related to breathing, namely the tidal volume andits first-order time derivative (e.g., the rate of tidal volume changesover time or airflow). There are two methods to measure tidal volume:direct tidal volume measurement and indirect tidal volume measurement.Direct tidal volume measurement is performed with a mouth spirometer,which is comprised of a turbine within a tube that spins at a rateproportional to the volume of air that the patient inhales or exhales.Indirect tidal volume measurement is performed with an abdominal belt(or any other geometric measurement of the patient's chest, as describedherein) that measures the patient's abdominal circumference changesduring breathing (as shown in FIG. 1). Greater abdominal circumferencemeans inhalation, and less abdominal circumference means exhalation. Anabdominal belt does not directly measure the tidal volume. To convertchanges in abdominal circumference into a physiologically meaningfulquantity, the hardware box 102 associates the abdominal circumferencechanges with the estimated lung volume determined via the 3D spatialposition localizer 300. For example, chest expansion is proportional toabdominal expansion during respiration. When used together, measurementsby the abdominal belt and 3D spatial position localizer 300 can be usedto estimate the lung's air content.

The term tidal volume, as used herein, means a difference between acurrent lung volume and a predefined baseline (e.g., a volume duringmaximum exhalation of a normal breath without extra effort applied, avolume during maximum inhalation of a normal breath without extra effortapplied, or any other suitable fiducial volume). Based on the ideal gaslaw, differences in air density between room air and internal air leadto air in the lung expanding 11% more than the tidal volume. To conservemass, the body expands 11% more volumetrically than the volume of airinhaled. Therefore, the lung's tidal volume can thus be calculated byusing an external measurement of the body that is calibrated to internalair content. Moreover, the 3D spatial position localizer 300 provides asecondary check of both the air content and the accuracy of the tidalvolume measurement by identifying the patient's volumetric expansionduring breathing. The volumetric expansion of the body is compared withestimates for the volume of air in the trachea, lungs, and bronchi fromthe x-ray images.

Section 1.3—Heart Phase Sensor 112

As shown in FIG. 1, cardiac phase is measured (e.g., by heart phasesensor 112) with either an electrocardiographic (ECG) monitor or a bloodvolume pressure device. For example, using the ECG monitor, a clinicianplaces leads on each of the patient's arms and places a ground lead onthe patient's lower left side of the abdomen (away from the diaphragmand the abdominal belt). The human heart generates a periodic andstationary electrical signal, with characteristic features thatcorrespond to the heartbeat phase. A stationary signal is one that is astochastic process whose joint probability distribution does not changein time. The blood volume pressure device uses a light source and aphoto sensor to measure light attenuation in a patient's finger.Circulating blood volume, which is driven by the heartbeat, results invarying light attenuation magnitudes in the patient's finger. The lightattenuation magnitude is directly proportional to the cardiac phase.

Typically, the digital diagnostic x-ray unit (e.g., x-ray unit 108) isturned on with an analog plunger that attaches to a plug port. The plugport is uniquely configured to accept a plunger with a specific pinconfiguration. In every pin configuration, there is an “acquisitionpin,” which accepts the voltage signal that turns on (e.g., gates) thex-ray unit. When an end-user depresses a plunger, the plunger sends avoltage pulse to the digital diagnostic x-ray unit, which activates theimaging beam through the patient's body.

As shown in FIG. 1, the hardware box 102 uses a connector cable tocommunicate the same voltage pulse (e.g., gating signal) from theacquisition software to the digital diagnostic x-ray unit 108. Thevoltage pulse signal turns the digital diagnostic x-ray beam on (e.g.,gates the x-ray beam) when the voltage pulse signal surpasses apredefined voltage threshold, and it turns the x-ray unit 108 off whenthe voltage pulse signal on the pin becomes less than the predefinedvoltage threshold. In some embodiments, the hardware box 102 creates asquare wave signal with a pulse height greater than the predefinedvoltage threshold and maintains the pulse height for the duration of theimage exposure. This is to say that a square pulse with Y voltage thatlasts for X seconds is generated for the x-ray unit 108 to take an x-rayimage of the patient. Sub-threshold voltages less than Y do not triggerthe scanner, such that the value of Y must be greater than thepredefined voltage threshold to initiate the x-ray image. Pulse durationX is the amount of the image's exposure time, beginning the moment thatvoltage Y exceeds the predefined voltage threshold and ending when thevoltage drops below the predefined voltage threshold. The voltage'sdropping below the predefined voltage threshold turns the x-ray unit 108off. The pulse duration is defined by the manufacturer's specificationsbut is generally in the order of a few milliseconds.

Section 2. Acquisition Software 104

The acquisition software 104 is designed to collect the hardware box102's measured spatial, heart and lung time series and determine when totrigger the x-ray unit 108 to acquire an x-ray image at a specificbreathing and cardiac phase. The acquisition software 104 thenaccurately overlays (e.g., synchronizes) the measured heart and lungphases, processes (e.g., filters) the collected biometric time series,identifies appropriate imaging times, and creates an electronic triggersignal for the digital diagnostic x-ray unit 108. The electronic triggersignal (e.g., gate signal) turns the x-ray unit 108 on, acquiring asnapshot image of the chest geometry. The spatial, heart, and lungvalues that are associated with the snapshot are recorded to define thechest's surface geometry when the image was taken. The entire process isautomated and is user-input-independent. As shown in FIGS. 1 and 2, theprocess implemented by the acquisition software 104 includes foursubsidiary components: Section 2.1 (Synchronization Module 114), Section2.2 (Signal Processing Module 116), Section 2.3 (Logic Algorithm 118),and Section 2.4 (Trigger Generation Module 120).

Section 2.1—Synchronization Module 114

Inputs to the synchronization module 114, including 3D spatial positionlocalizer 300's signal, breathing phase sensor 110's signal, and heartphase sensor 112's signal are synchronized with the x-ray unit 108'sclock by the synchronization module 114. Note that the physiologicalbiometric signals are asynchronously collected, and therefore requiresynchronization. One source of asynchronicity is that the breathingcycle is slower than, and completely independent from, the cardiaccycle. As explained previously, the breathing cycle and the cardiaccycle are measured separately with different sensors. Thesynchronization module 114 is configured to synchronize the breathingand heart phase sensors with the acquired images. When an image istaken, the image displays the chest's anatomic geometry at a moment intime. That moment in time is recorded using the x-ray unit 108's nativetiming system, which is not necessarily synchronized with the breathingand heart sensor biometric time series.

It should be noted that time alone does not differentiate between timeperiods of irregular breathing versus time periods of regular breathing.In other words, if time is the sole defining dimension of breathingphase, an image taken during a normal breath and an image taken duringan abnormal breath (like a cough) are computationally indistinguishablefrom one another. FIG. 4 depicts examples of two breaths 400 (e.g., 400a and 400 b) from the same individual sharing the same maximuminhalation phase in time but with radically different tidal volumesaccording to some embodiments of the present disclosure. Whensuperimposed on one another, despite having a similar maximum inhalationphase, the two breaths 400 are in fact dissimilar because they havedifferent tidal volume magnitudes. In some embodiments, tidal volumerefers to a value of a volume (e.g., in ml) measured relative to abaseline volume. For example, the baseline volume represents the minimumvolume of the lung (e.g., at maximum exhalation) during a normal breathof the patient (e.g., without extra effort or force to exhale). In someembodiments, the baseline volume changes for each patient. In someembodiments, the baseline volume is represented as 0. In someembodiments, the tidal volume is measured at a point in time. Arepresentation of changes in the tidal volume over a period of time isshown in FIG. 4.

To overcome the issue with the time dimension, the GREX imaging system100 defines the breathing phase by the physiologic values that areacquired from the various physiologic sensors in the hardware box 102,which are more informative breathing phase dimensions compared to time.The synchronization module 114 serves primarily to allow a seamlesstransition between the x-ray unit 108 and the GREX imaging system 100.In some embodiments, the acquisition software 104 uses a 30-second longtraining window, discussed in detail below within Section 2.2, duringwhich the collected tidal volume time series observations are used tocalculate tidal volume percentiles. The acquisition software 104 usesthe tidal volume percentiles to define the breathing phase rather thanthe peak-to-peak time interval of a periodic cosine wave. Theacquisition software 104's tidal volume percentiles are a moreinformative method of defining the lung geometry compared to thepeak-to-peak periodic cosine curves because of breath-to-breath tidalvolume variations.

FIG. 5 depicts examples of tidal volume percentiles (two bottomsubplots) for a regular breathing patient (upper left subplot) and foran irregular breathing patient (upper right subplot), respectively,according to some embodiments of the present disclosure. Toquantitatively assess the tidal volume histograms for irregularbreathing, a ratio between normal inhalation tidal volumes and extremeinhalation tidal volumes is used as a metric of the breathing phase. Theratio has thresholds that define the probability of the patient havingbreathed irregularly. As shown in the two bottom subplots of FIG. 5,vertical lines show where the 85th, 90th, 95th, and 98th percentiletidal volumes are located in the tidal volume histograms. In the regularbreathing case (lower left-side subplot of FIG. 5), the more normaltidal volume percentile values (85th and 90th) are located closer to theextreme tidal volume percentile values (95th and 98th) than in theirregular breathing case (lower right-side subplot of FIG. 5).

FIG. 6 is a schematic flow chart of a synchronization process 600between different sensors in the hardware box 102 and the diagnosticx-ray unit 108 according to some embodiments of the present disclosure.Note that the hardware box 102 continuously collects the tidal volumepercentile-defined breathing phases, the ECG-defined cardiac phases, andthe 3D spatial position localizer 300 defined coordinates of the chestgeometry. The sensor signals supporting these measurements need to besynchronized with one other before being synchronized with the x-rayunit 108. To do so, measurement channel differences and cable electricalresistivity differences between different sensors are also corrected bymatching trace lengths using impedance matching in a digital-to-analogconverter. Because the x-ray unit 108's clock (e.g., timing system) isusually not synchronized with the hardware box 102's clock, theconnector cable is configured to connect to the data acquisition boardand interface it with the x-ray unit 108's clock. The x-ray unit 108'sclock passes through a distribution buffer and is trace-matched for eachchannel in the analog-to-digital converter. The converted digitalsignals are passed into a field-programmable gate array where thesynchronization across all signals is ensured. When the acquisitionsoftware 104 properly synchronizes the breathing and heart phase sensorsignals, the result should be similar to the example shown in FIG. 7.

To avoid the unwanted radiation exposure for the patient, theacquisition software 104 does not send any triggering signals toactivate the x-ray unit 108 via the connector cable without appropriatesynchronization between different components of the GREX imaging system100. In some embodiments, the 30-second training window is used forverifying the synchronization between the hardware box 102's clock andthe x-ray unit 108's clock. Therefore, the 30-second training windowshould contain 30 seconds worth of samples. If every sensor in thehardware box 102 as well as the x-ray unit 108's clock do not showexactly 30 seconds worth of samples, then synchronicity has failed tooccur. To that end, if this aforementioned checking procedure contains adiscrepancy, the synchronization system will restart to correct thediscrepancy. It should be noted that the 30-second training window isfor illustrative purpose and one skilled in the art would understandthat the length of the training window varies as long as there issufficient data for performing the synchronization process.

Section 2.2—Signal Processing Module 116

After the spatial position, breathing phase, and cardiac phase signalsare synchronized, the acquisition software 104 processes the sensorsignals to remove noise and ultimately predicts accurate tidal volume ofthe patient. Noise in the measured lung and heart time series comes fromthe sensor electronics, the electrodes, as well as from backgroundelectrical signals. A suite of filters that specifically maintainstemporal accuracy removes the noise from the measured lung and hearttime series such that the biometric time series maintain temporalaccuracy after being filtered by the suite of filters.

In some embodiments, two distinct filters (e.g., wavelet filters) areused to remove signal drift and noise from the biometric time series.Signal drift skews measurements taken over time so that measurements atthe beginning of the data collection are not consistent withmeasurements taken at the end of the data collection. Signal noise isnot physiologic in nature and causes serious problems when calculatingthe patient's airflow from tidal volume measurements. FIG. 8 is aschematic flow chart of a drift and signal noise removal process 800according to some embodiments of the present disclosure.

The acquisition software 104 needs smooth tidal volume time series tocompute the first order time derivative of the tidal volume, e.g.,airflow. If the tidal volume time series were not smooth, the firstorder time derivative of the tidal volume would not yield a smoothcurve; rather, the curve would contain discontinuities that violate thebiophysical realities of breathing. FIG. 9 depicts an exemplary breathplotted as tidal volume versus time according to some embodiments of thepresent disclosure. FIG. 10 depicts the same breath shown in FIG. 9plotted as airflow versus tidal volume according to some embodiments ofthe present disclosure, which is a continuous closed loop used by thepost-processing software 106 for biomechanical modeling (described inSection 3.1).

The acquisition software 104 performs two distinct functions using thefiltered and temporally accurate time series curves. The acquisitionsoftware 104's first function is to generate a breathing phaseprediction using a short prediction horizon. FIG. 11 is a schematic flowchart of the breathing phase prediction process 1100 according to someembodiments of the present disclosure. The short prediction horizon isthe prediction algorithm's “look ahead time.” The prediction algorithmpredicts the future moment in time at which the desired tidal volume andairflow (e.g., breathing phase) will occur. The “desired” breathingphase is targeted so that the diagnostic x-ray unit 108 can be triggeredto acquire the desired chest geometry.

A short prediction horizon also mitigates another source of inaccuracyin breathing prediction, e.g., breath-to-breath variations in breathingamplitude and breathing period. As the limit of prediction horizonapproaches zero, the change in the lung geometry approaches zero (e.g.,the lung geometry is deemed to be virtually constant). In other words,the lung geometry is very unlikely to change dramatically during a shortprediction horizon. The short prediction horizon therefore reduces theimpact of human breathing variation on the breathing motion model'spredictive accuracy.

Temporally accurate, filtered tidal volume time series serve as inputvalues for the breathing prediction algorithm. The breathing predictionalgorithm provides a fast, real-time, and accurate forecast of thebreathing phase. For example, the breathing prediction algorithm isbased on an autoregressive integrated moving average (ARIMA). ARIMA isappropriate for breathing prediction because ARIMA models do not assumethat input values are stationary, and is comprised of polynomials. Thepolynomial coefficients of the ARIMA model are estimated during the30-second training window taken at the start of the imaging study. Thenumber of polynomial coefficients of the ARIMA model, e.g., model order,is checked with nonlinear optimization that seeks to minimize aninformation criteria search function to reduce or eliminate overfitting.If the model order is optimal for the collected training data, thenbuilds a tidal volume histogram (discussed in Section 2.1) andcalculates the probability density function using a log-likelihoodobjective function. The tidal volume distribution is to check forirregular breathing as discussed in Section 2.1. If irregular breathingwas detected, the training data is discarded and reacquired. Ifirregular breathing was not detected, the training data and probabilitydensity function is used to estimate the ARIMA model coefficients with amaximum likelihood approach. The 30-second training window also servesas an equipment check prior to imaging. FIG. 11 shows the flowchart forpredicting the breathing phase.

The acquisition software 104's second function is to identify thecardiac phase so that the heart is in the same phase in each desiredchest geometry. The prediction horizon's duration is a crucial parameterin the acquisition software 104's endeavor to accurately predict humanbreathing because human breathing is a quasi-random function (becauseeach breath has some unique aspect of its own). In some embodiments, theprediction horizon's duration is longer than the sum of the digitaldiagnostic x-ray unit 108's latency time and the x-ray imaging'sexposure time. The sum of the digital diagnostic x-ray unit 108'slatency time and the x-ray imaging's exposure time is very short, on theorder of 10 milliseconds. As a result, the prediction horizon's durationis also short (on the order of 1-2 sensor measurement samples at anoperating frequency of 100-1000 Hz).

When the acquisition software 104 looks for coincidence between thecardiac and breathing phases, the probability of having phasesrepresented by a single point in each time series align is low. As aresult, an imaging method that looks for single-point coincidences takesa longer time to complete since the acquisition software 104 has to waitfor low probability coincidences to occur. In contrast, the cardiacgating window extends the size of the coincidence window so that theimaging study takes less time.

To further reduce computation time in the signal processing software,the signal processing software does not predict cardiac phase. Instead,the signal processing software targets a specific gating window in whichthe heart is not rapidly displacing the lung. FIG. 12 depicts anexemplary gating window in time chosen based on the locations of T waveand P wave in the ECG signal such that the heart induced lung motion ischanging slowly according to some embodiments of the present disclosure.The dotted line is heartbeat-induced lung motion. Lung motion rate ofchange (e.g., velocity) is the slope of the dotted line. When the dottedline's slope is small, the rate of change is also small, making thecorresponding cardiac phase an ideal gating window. FIG. 12 shows thatthe gating window occurs (consistently) between the T wave and P wave,more skewed toward the P wave. There is minimal lung motion caused bythe heart beat in the gating window.

The preceding paragraph discusses how to identify the ideal cardiacgating window that would minimize the heart's physical effect on thelungs while still maintaining a window of opportunity for the targetedbreathing phase to coincide with the desired cardiac phase. In someother embodiments, the GREX imaging system 100 predicts rather thangates the cardiac phase based on a signal processing difference thatdistinguishes the cardiac phase from the breathing phase, e.g., thecardiac phase is periodic and stable. Because the cardiac phase isperiodic and stable, an unsupervised multi-layer perceptron using abackpropagation approach can be used to predict the next heart beatbased on the pattern extraction rather than a time series predictionprocess.

FIG. 13 is a schematic flow chart of another GREX process 1300 using thecardiac phase prediction instead of real-time identification of acardiac gating window according to some embodiments of the presentdisclosure. In this case, twenty seconds of the training window (20-22heartbeats) is used for training the algorithm while the remaining tenseconds (10-11 heartbeats) is used for validating the multi-layerperceptron node weights. Node weights are iteratively determined throughgradient-descent optimization until the model error in the training setis minimized. The trained model is applied to the 10-second validationdata and node weights are recalculated if the multi-layer perceptronprovided poor prediction of the cardiac phase in the validation data.

Section 2.3—Logic Algorithm 118

There are known medical algorithms and systems for identifying an ECG'sT wave and P wave within a cardiac cycle. Because the heart phase sensor112 takes continuous measurements of the cardiac cycle, the timeinterval between the T wave and the subsequent P wave (which is equal toa constant fraction of the cardiac cycle, and is thus proportional tothe heart rate) is also known. The ECG features within the time intervalcan be used by the logic algorithm 118 to introduce a short time lagbefore initiating the gating window such that the gating window maystart, e.g., halfway between the T and P waves and close after the logicalgorithm 118 identifies the P wave.

FIG. 14 depicts an example of triggered x-ray image capturing windowscorresponding to different breathing phases of a breathing cycle, fromleft to right, early exhalation, late exhalation, maximum exhalation,early inhalation, late inhalation, maximum inhalation of a breathingcycle according to some embodiments of the present disclosure. In thisexample, the acquisition software 104 identifies a minimum of sixbreathing phases that represent a single breath cycle. During thetraining period, the acquisition software 104 generates a distributionof samples and the logic algorithm 118 computes the tidal volumepercentiles that will define the logic algorithm 118's targetedbreathing phases. The arrows shown in FIG. 14 denote the six cardiacgating windows that coincide with the targeted breathing phases forwhich the logic algorithm 118 would create an imaging trigger signal.Once the acquisition software 104 acquires a breathing phase, it createsan automated check that prevents future redundant imaging of the samebreathing phase.

FIG. 15 is a schematic flow chart of an image acquisition triggeringprocess 1500 according to some embodiments of the present disclosure.The cardiac phase sensor measurements are used to identify the cardiacgating window as previously described in connection with FIG. 12. Thebreathing phase sensor 110's measurements are used to forecast thebreathing phase as previously described in connection with FIG. 11. Thelogic algorithm 118 identifies coincidence between the cardiac phasegating window and predicted breathing phases. When a coincidence isfound, a list of breathing phases is checked to determine if thebreathing phase has already been acquired or not. If the breathing phasewas previously acquired, an imaging trigger pulse is not created. If thebreathing phase was not previously acquired, an imaging trigger pulse iscreated, which takes a snapshot of the patient anatomy. The breathingphase, cardiac phase, and 3D spatial position localizer 300 measurementsare recorded and tagged with the image. If all breathing phases havebeen acquired, the breathing phase list is updated to prevent redundantimages from being taken.

Section 2.4—Trigger Generation (Gating)

X-ray unit 108 has a port that contains a series of electrical pins. Oneof those pins accepts an electrical impulse that defines the radiationexposure timing and duration. Based on the logic algorithm 118'sidentified breathing phases within a cardiac gating window, the triggergenerator generates a square wave trigger as an electrical impulse. Afiber optic cable with a vendor-specific plug attachment carries thegenerated trigger signal to the x-ray unit 108.

Section 3. Post-Processing Software

The biometrically-informed imaging trigger identified by the hardwarebox 102 (Section 1) and acquisition software 104 (Section 2) providesbetter quality inputs (and remove poor quality inputs) to the imagereconstruction algorithm. Specifically, the quality enhancement arisesfrom the fact that image reconstruction and image post-processingtechniques are enhanced through the process of acquiring biometricallytargeted images during normal breathing. The act of biometricallytargeting images during the normal breathing allows for more accurateassociation of multiple images of the same patient's anatomic geometrytaken from different angles and at different times (e.g., differentbreaths) because the fundamental assumptions of the underlying radiologymathematics assume anatomical equivalence across the various probedimaging angles. The enhanced images serve as observations and thebiometric signals serve as inputs for a complex biomechanical model ofthe chest geometry.

Section 3.1—Digital Tomosynthesis-Based GREX Image Acquisition

Multiple imaging angles are needed to reconstruct a 3D volume. In thecontext of the GREX imaging, each angle needs to be acquired for eachbreathing phase. The acquisition software 104 (Section 2) creates atrigger signal that allows the x-ray unit 108 to repeatedly image thechest in a specific geometry. Identical geometries imaged at differentimaging angles and different breaths constitute a set of 2D projectionimages that are used to reconstruct the 3D volume. There are many knownmethods of reconstructing a 3D volume from the multiple 2D projectionimages. One such exemplary method is a convolution-back-projectionalgorithm for direct reconstruction of a 3D density function using a setof 2D projections called “FDK image reconstruction algorithm” disclosedin Feldkamp, L. A., Davis, L. C., Kress, J. W. “Practical cone beamalgorithm”. J Opt Soc Am 1, 612-619 (1984).

FIG. 16 is a schematic block diagram of variables used in the imagereconstruction algorithm according to some embodiments of the presentdisclosure. Once a single projection is acquired, the x-ray unit 108moves an angle ß and the detector plane moves to stay perpendicular tothe x-ray unit 108. In some embodiments, a patient is moved and thex-ray unit 108 remains in a same position between acquired projections.FIG. 17 schematically shows an example of how the x-ray unit 108 anddetector panel 304 from FIG. 3 move to acquire multiple imaging angles.For example, x-ray unit 108 moves from position 1700 a to position 1700b to position 1700 c. Detector panel 304 moves from position 1702 a toposition 1702 b to position 1702 c. The detector plane is rotatingaround the axis parallel to the detector plane, and the imaging planerotates around its parallel axis, z. The position of a pixel in thedetector plane and a corresponding pixel in the imaging plane isseparated by a distance, s. Anatomic information (f(x,z/y)) in the imageplane ((x, z) plane), at an arbitrary depth y is calculated by Equation(1).

$\begin{matrix}{{f\left( {x,{z/y}} \right)} = {\frac{1}{N_{0}}{\int_{m\; i\; n\;\beta}^{m\;{ax}\;\beta}{\frac{d^{2}}{\left( {d - s} \right)^{2}}{\int_{- \infty}^{\infty}{\frac{d}{\sqrt{d^{2} + p^{2} + \xi^{2}}} \times {R\left( {\beta,p,\xi} \right)}{h\left( {\frac{d \cdot t}{d - s} - p} \right)}{W(p)}{dpd}}}}}}} & (1)\end{matrix}$

In Equation (1), N₀ is the total number of projections, β is the angleof each projection, d is the source-to-image plane distance, s is thepixel-to-detector distance, p is the detector axis perpendicular to therotation axis, ξ is the detector axis parallel to the rotation axis,R(β,p,ξ) corresponds to cone beam projection data (e.g., the function Ris the detector readout for a given angle, p coordinate, and ξcoordinate), h is the convolution filter, and W(p) is a weightingfunction. Basically, Equation (1) represents a combination ofconvolution, back-projection, and weighting steps.

Information at points that lie in the mid-plane is calculated from theprojection data along the intersection of the detector plane and themid-plane (y=0). Projections that intersect the detector plane along aline parallel to the mid-plane, but not in it (constant, nonzero y),themselves define a plane. This plane is treated as if it were themid-plane of another, tilted arrangement. If a complete set ofprojections are acquired (note that “complete” denotes the case whereall rotation angles about the normal are acquired) the tilted plane'sdensity is reconstructed using the Radon transform. Acquiring a completeset of projections requires a 360° rotation of the source around theimaging object along a circle in the tilted plane; In CT imaging, forexample, a full 360° rotation around the imaged object occurs. Note thatthe bolded words “the imaging object” imply—more accurately, the boldedwords explicitly communicate and define—the fundamental assumption ofthe Radon transform (folded into Equation (1)'s R(β,p,ξ) term) that, ifviolated, stymies the reconstruction's representativeness of theunderlying ground truth anatomy that was imaged: “The imaging object”implies that Radon transform inputs are assumed to be different angularprobes of one single, fixed, non-moving and non-changing in time andspace, stationary object of anatomy. The GREX imaging's biometrictargeting (indeed “pre-selection”) of only the accurate (thegeometrically identical breathing phases that are identical despiteoccurring in different breaths) Radon transform inputs adheres to thetransform's fundamental assumption definitionally and practically, sincebreathing phase (that is: changing in the time domain) is for GREXdefined strictly geometrically and anatomically and physically (e.g., adefinitionally correct formulation) and also practically with GREXimaging's uniquely short prediction horizon and prospective biometrictargeting.

Note that 360° rotation is not practical for GREX imaging because thehigh number of projections needed to reconstruct the torso's 3D volumeincrease clinical procedure time and increase patient dose of radiation.Instead, GREX imaging may use projection angles ranging up to 90°between −45°≤β≤45° or 0°≤β<90°. One skilled in the art would understandthat experimental testing may identify more optimal projection angleranges, but the theoretical projection angle ranges does not exceed 90°.In some cases, the −45°≤β≤45° is likely preferable to the 0°≤β<90°because the −45°≤β≤45° keeps the radiation dose from the imagingprocedure as low as reasonably achievable. The x-ray photons traverseless human tissue in the −45°≤β≤45° projection angle range compared tothe 0°≤β≤90° projection angle range, and therefore can be lower energyphotons thereby depositing less dose, as shown in FIGS. 18A and 18B.

To produce a high quality 2D image without delivering excessiveradiation dose, photon energy must be high enough to partially penetratethe patient's body but not too high so that the photons totallypenetrate the patient. Thicker patients require higher photon energythan thinner patients. When |ß|>45°, the human body is substantiallythicker than when |ß|<45°. In general, as β→0° the photon energydecreases. In some embodiments, the GREX imaging system 100 acquires sixbreathing phases at five distinct projection angles for a total of 30projections although other different numbers of projections may bepossible depending on the specific application of the GREX imagingtechnology. For example, in breast tomosynthesis, the symmetriccurvature of the breast means that the breast surface is essentiallyequidistant from the source at all projection angles, meaning thattomosynthesis is well suited for breast. Furthermore, the breasts do notmove when placed in a cradle, a typical clinical tomosynthesis approachthat could be analogized to breath-hold lung imaging.

With the lung and heart motion challenge resolved by the GREX-basedgeometric definition of breathing phase plus GREX-based highly accurateand fast prospective targeting prediction algorithm (Section 2.1 and2.2, respectively), the GREX imaging system 100 can handle the varyingtorso curvature with the biometric surface information gathered by 3DSpatial Positioning Localizer (Section 1.1). Biometric surfaceinformation also assists in the image post-processing to account forattenuating tissue density in the imaging field, thus quantifyingpreviously neglected sources of attenuation and ultimately resulting inhigher fidelity image reconstruction. In sum, the GREX imagingtechnology makes it possible for the digital tomosynthesis to work fornon-breath-hold (“dynamic”) lung and heart imaging.

GREX-based approach to 3D volume reconstruction can be eitherpatient-specific (personalized medicine, with a personalized number ofdiscrete angles and arc subtended) or used as a “universal minimumprocedure time and universal minimum delivered dose” (in theneighborhood of 5 discrete angles, plus or minus 3 angles depending onthe statistical reconstruction methods used and number of priorGREX-based datasets available for the person).

As shown in FIG. 19, when the rotation of the x-ray unit 108 subtends asmall range of angles, the depth resolution is lower than when therotation of the x-ray unit 108 subtends a wider range of angles. Anymotion, no matter how small, causes image artifacts in the reconstructedimage which commonly leads to false-positive cancer detection. But theGREX imaging system 100's unique hardware box 102 (Section 1) collectsbiometric signals that inform the acquisition software 104 (Section 2)when to take an image so that the chest geometry is clinicallyidentical, thereby making smart chest digital tomosynthesis possible.

In some embodiments, the GREX imaging technology allows the projectionangle to vary during one breathing phase whereas multiple projectionangles captured at different time points (as defined by GREX imaging'squantitative definition of “breathing phase”) still all correspond tothe same breathing phase because they are deemed to be all capturing onechest geometry. Moreover, the GREX-based tomosynthesis approach allowsthe acquisition of depth information because the detector's final photoncount numbers across all pixels and the distribution of photon counts inspace at the detector surface are reflective of a single chest geometrythat has been probed at multiple angles.

Note that the GREX imaging technology allows the x-ray unit 108 anddetector panel 304 to be mounted on unmotorized arms or stands. Themanual arm's role in an exemplary GREX imaging procedure is describedand illustrated in FIG. 20 as follows:

-   -   1. At the β₁ position, all the requisite 6 chest geometries        (a.k.a. “GREX's quantitatively defined breathing phases”) are        imaged.    -   2. Then the clinician physically reorients the x-ray unit 108        and the detector panel 304 to image the patient at position β₂.    -   3. The orientation of the x-ray unit 108 and detector panel 304        relative to the patient is verified by the 3D Spatial Localizer,        which allows imaging to take place at β₂.    -   4. Now at β₂: If only 4 out of the 6 required chest geometry        images are acquired during the first breath, the patient simply        continues breathing as normal at position β₂ for subsequent        breaths until the remaining 2 chest geometry images are        acquired.    -   5. Now that all 6 breathing geometries have been acquired at β₁        and at β₂, the x-ray arm can now be relocated to acquire each        imaging angle in turn from (β₂→→β₃; β₃→β₄; β₄→β₅).    -   6. By the end of the procedure, the x-ray arm only moves a total        of 4 times, as denoted by the → arrow in the workflow (β₁→β₂;        β₂→β₃; β₃→β₄; β₄→β₅).

By moving the arm only 4 times during the procedure, the GREX imagingtechnology minimizes the length of the procedure, the extent ofclinician-equipment interaction during the procedure, and the extent ofwear-and-tear to the x-ray arm because the clinician is not interactingwith the x-ray arm as much as moving the arm from ß1 through ß5 for all6 breathing phases (e.g., performing 30 x-ray equipment reorientations).

In some embodiments, the 3D Spatial Positioning Localizer allows fora-priori position checks and safety interlocks of three individualelements separately—namely the patient's posture and position, the x-rayunit 108's position, and detector's position in space—as well as thecollective consistency of each element's position/alignment upon an axis& relative to the position of the other elements. This a-priori positioncheck and safety interlocks result from GREX imaging's defining thebreathing phase geometrically. Therefore, the GREX imaging system 100(via the prospective breathing phase prediction algorithm) is inherentlysuitable for giving users software-based safety and quality assurancecontrol capabilities that (in the case of a safety interlock) preventthe triggering algorithm from initiating “beam on” if either (or both)the x-ray arm or detector or patient posture were incorrectly positionedin space (or inconsistent) for a specific angle, ß.

In some embodiments, since the 3D Spatial Positioning Localizer recordsthe coordinates of all equipment during a procedure, imagereconstruction techniques can benefit from the (a-posteriori)quantification of each ß angle and its associated uncertainty.

FIGS. 21A-21B illustrate an exemplary block diagram illustrating how theGREX imaging system 100 reconstructs static image cubes from the 2Dprojection data taken from each imaging angle position according to someembodiments of the present disclosure. Specifically, FIGS. 21A-21Billustrate an exemplary GREX imaging case where the coronal and sagittalviews themselves form the outer limit/boundary of the imaging anglepositions (e.g., projection angles). The i^(th) plane x-ray projectionis taken at a single imaging angle position (β_(i)) for each of the 6breathing geometries. The sum of the i=1 through i=n Plane Projectionsthen inform reconstruction (Equation 1) of depth information in (x,y,z)of the (v₁,f₁) geometry that has been probed using the i=1 through i=nProjections, each of which has a plane of focus at a unique (compared tothe other projections) depth.

2D projection data is acquired six times (for early inhale (EI), lateinhale (LI), max inhale (MI), early exhale (EE), late exhale (LE), andmax exhale (ME) at each projection angle (ß). For simplicity, theprojection angles range from 0° to 90°. The x-ray unit 108 will move tothe next projection angles only when all breathing phases are acquiredat the prior projection angle. The 2D projections are sorted accordingto breathing phase so that a static image cube is reconstructed (e.g.,from the β_(i)=1 to the β_(i)=n projection angles that probed the chestgeometry at (v1,f1)) to represent the chest volume at each breathingphase. The static image cubes are then temporally interpolated using themethods discussed in Section 3.3 below.

The x-ray projections acquired at each angle ß are taken at the targetedbreathing phases identified using the ARIMA model (Section 2.2). Afterthe targeted breathing phases are acquired, the x-ray unit 108 moves tothe next imaging angle position. FIG. 22 shows an example that onlymaximum inhalation and maximum exhalation are acquired by theacquisition software 104. In the example, the maximum inhalation andmaximum exhalation are imaged at ß₁ then the x-ray unit 108 moves to ß₂so that maximum inhalation and maximum exhalation phases can be acquiredat ß₂. When the targeted breathing phases are acquired at all theimaging angle positions, the images are sorted according to theirrespective breathing phases. Sorting x-ray images according to thebreathing phase groups the projections according to thebiometrically-defined six breathing phases. Although the breathingphases are acquired during different breaths, the accurate ARIMA modelensures that the tidal volume and airflow parameters are identicalbetween x-ray projections captured at different projection angles. Notethat GREX imaging defines “the same chest geometry” biometrically, suchthat the lung resides in “the same chest geometry” at multiple timepoints. GREX imaging probes the same biometric breathing phase atdifferent angles because the ARIMA model (Section 2.2) is a fastprediction method. Chest geometry prediction errors are minimized usingthe short prediction horizon of the ARIMA model. The associativeequivalence of each individual angle's depth information (to, inaggregate, generate real structural depth information) depends on theequivalence (consistency, within approximation tolerance) of chestgeometric position across the different probed angles. As such, thebreathing phase prediction accuracy ensures the successful imagereconstruction.

The breathing phase-sorted projections are used to create static imagecubes through the previously discussed canonical FDK imagereconstruction algorithm given in Equation (1) (or a similar cone-beamgeometry image reconstruction algorithm). The image reconstructionalgorithm uses the breathing phase-sorted projections and createsbreathing phase sorted, static image cubes. Each breathing phase willhave a separate image cube. The static image cubes are called staticbecause they represent anatomy in only one breathing phase. Static cubesthat represent all of the targeted breathing phases are combined andtemporally interpolated (described in Section 3.3) to create a 3D imagecube movie from 3D static image cubes.

GREX imaging system 100 keeps the radiation dose to the lowest levelsreasonably achievable through statistical image reconstruction. Eachacquired image increases the dose of entire imaging process (aclinically undesirable consequence) but provides additional informationfor image reconstruction (a clinically desirable result). Traditionalforms of image reconstruction, based on the Fourier transform orfiltered back projection, have the tendency to display image artifactsdue to an inability to handle missing information, e.g., missingprojection angles, ß. For example, if a projection is taken every 10°instead of 5°, there will be half as much information available forcreating a static image cube, but only half the dose was delivered withthe former compared to the latter. Statistical iterative imagereconstruction addresses the missing information caused by having anincomplete image dataset.

There are numerous statistical image reconstruction algorithms thatalready exist which GREX imaging system 100 can use to complete the taskof image reconstruction (e.g., to construct the static image cubes).However, GREX imaging system 100 improves on traditional statisticalimage reconstruction algorithms by implementing a unique feedback stepand complying with the law of conservation of mass-based boundarycondition.

Basic principles of physics can be applied to GREX's statistical imagereconstruction because GREX images are biometrically defined bybiophysical quantities that are governed by physical law. Bybiometrically tagging each image and the resulting image cube, as wellas by collecting the continuous biometric data stream during theprocedure even when not imaging the patient, the breathing dynamics ofmass exchange (inhalation and exhalation) and volume change are known(making it possible to solve for the unchanging lung tissue mass that isconsistent over the course of the scan). The law of conservation of masscan be applied because static image cubes can be constructed from amoving organ such as lung for the first time. This is due to theprospective prediction/triggering algorithm's speed and accuracy(Section 2.2 and 2.3) which accurately labels and acquires the samechest geometry at different moments in time. Stated differently, thetissue mass in a static image cube should not change (e.g., does notchange due to the law of Conservation of Mass) from one static imagecube to the next. Based on the ideal gas law, the ratio of roomtemperature air to air inside lung is 1.11. Given the tidal volume ofthe image cube from sensor data, and with the 1.11 ratio and themass/volume air curves for deviations from room temperature, the mass ofthe inhaled air (in absolute terms and also in relative terms as a ratiobetween two different breathing phase image cubes) can be determined.

GREX imaging's conservation of mass-based boundary condition is highlyuseful because, for instance, the presence of air may artificiallydarken a voxel, thereby adversely affecting the ability of thestatistical image registration algorithm to accurately determine objectdensity. By correcting acquired projections for air volume differencesand consistently isolating a quantity that should be constant (e.g.,lung tissue mass) over the course of the scan, GREX imaging producesmore accurate image reconstruction for generating the static imagecubes.

Considering two GREX projections taken at different imaging angles butwith the same biometrically defined breathing phase, the volume of airin the lung is identical, but the way the air displaces tissue might bedifferent between the two projections and dim the brightness of a nodulein the second projection, which was affected and is erroneous, comparedto the first projection. The consequence of this error is that a pieceof tissue (“the nodule”) that was visible in the first projection is notvisible in the second projection, which will ultimately dull theintensity of “the nodule” (or cause it to be mistaken for background) inthe resulting image cube. GREX imaging's law of conservation of massboundary condition is implemented as a feedback step that would checkthat lung mass was conserved between the aforementioned image cube withthe erroneously dim nodule and a different (correct and anatomicallyrepresentative of “the nodule's” brightness) image cube from a laterbreathing phase. GREX imaging's feedback step corrects at the level ofthe erroneous image cube's second projection during reconstruction byupdating the expected geometry based on a simulation using the firstprojection as the gold standard. In this way, GREX statistical imagereconstruction would produce more accurate static image cubes.

In addition to pre-existing statistical image reconstruction algorithms,GREX's post-processing software 106 incorporates edge defining filters(discussed in Section 3.2), spatial boundary conditions (discussed inSection 3.2), and smooth transitions between breathing phases (discussedin Section 3.3) into the digital diagnostic x-ray images to improveanatomic imaging.

Section 3.2—Image Filters

A digital diagnostic x-ray image's quality depends on the x-ray unit 108settings and the image's anatomic study site. Each patient and anatomicsite has different electron densities, through which x-rays traverse togenerate an image. For example, imaging the femur requires a higherx-ray energy than the x-ray energy required to image the chest becausethe lung is mostly comprised of air, and the femur is comprised of bone.Given that higher energy x-rays penetrate the body at to a greaterextent than lower energy x-rays penetrate the body, the number of x-raysthat emerge from the body to reach the flat-panel detector are differentfor high energy x-rays and low energy x-rays imaging the same anatomicgeometry. Too many x-rays emerging from the body results in the flatpanel detector's overexposure, in a manner similar to overexposure inoptical photography. If the x-ray unit 108 setting is not optimal forthe anatomic image study site, the image quality will be greatlyreduced. In clinical practice, commercial vendors have devised imagingprotocols for their digital diagnostic x-ray units that roughly estimateoptimal x-ray unit settings for a selected anatomic site. But theserough estimates of optimal tube settings are not customized to addressthe potentially significant anatomic variations between anatomic siteswithin different patients (e.g. the stomach of an overweight man versusthe stomach of an average weight man). Indeed, the vendor community'sexisting imaging protocol settings, as just rough estimates, seldomresult in an optimal quality image.

If optimal x-ray unit settings or other imaging parameters are unknownprior to imaging (as currently the case within the medical community),the strategic deployment of digital image filters can improve the imagequality of non-optimal x-ray unit settings. An improved image enhancesthe visibility of anatomic features that are poorly visible to the humaneye. For example, in the coronal plane, every rib might not be visiblein a digital diagnostic radiographic image. The post-processing software106 filters the coronal plane images with an edge enhancing filter, likea Laplacian filter, to display the boundary of all ribs on the resultingimage even when the rib boundary on the original image is too subtle forthe human eye (e.g. the radiologist's eye) to detect. Thepost-processing software 106 overlays the filtered image with theoriginal image, which highlights the enhanced (e.g., post-filtration)and previously invisible rib edges onto the original image. Imagefilters that will be made available for the user to apply include theLaplacian filter, Hanning filter, Butterworth filter, Parzen filter,Wiener filter, Metz filter, Ramp filter, nonlinear spatial mean filter,and hybrid filters.

In some embodiments, the post-processing software 106 uses the 3Dspatial position localizer 300's skin surface measurements to calculateoptimal imaging parameters for images taken at each breathing phase. Asa patient breathes, the electron density of the body changes as more airis inhaled and the chest circumference increases. Increasing patientdiameter, decreasing distance between the patient and the x-ray unit108, and decreasing distance between the patient and the detector panel304 produce additional image noise in the resulting x-ray images. The 3Dspatial position localizer 300 tracks the patient's skin surfaceposition for each image in relation to the x-ray unit 108 and detectorpanel 304. This skin surface position tracking provides a uniquemeasurement for digital diagnostic x-ray studies.

The digital diagnostic radiology field currently relies on scaling ionchamber-measured dose index readings to the patient's approximatedbody-mass index. A radiology technician currently only takes twomeasurements: the first measurement with a tissue density equivalentsolid water cylindrical phantom with a 16 cm diameter, and the secondmeasurement with a 32 cm diameter materially-identical phantom. Thex-ray unit 108 has built-in protocols that are vendor-defined and “onesize fits all (patients)” for a particular anatomic location. Forexample, regardless of a patient's chest diameter, the vendor providesonly a single protocol with built-in imaging settings for thetechnologist to select. In other words, a man with a fat chest gets thesame imaging settings as a man with a skinny chest.

The 3D spatial position localizer 300 of the GREX imaging system 100produces a real-time and personalized measurement of a patient's chestdiameter. The measurement will inform the technologist in selectingx-ray unit settings that are personalized for the patient. When thepatient is breathing, the chest diameter is changing. A changing patientchest diameter prevents the technologist from optimally setting theimaging parameters to match the patient's chest diameter. Moreover, thereal-time and personalized measurement of a patient's chest diameter canbe used to remove image noise in post-processing procedures, and tosimulate an x-ray image taken with optimal imaging parameters.

FIG. 23 is a schematic flow chart of an image filtering process 2300that calculates a noise-free lung image and simulates an image takenwith optimal x-ray unit settings according to some embodiments of thepresent disclosure. After images are acquired as described in Section 2,the trachea is identified using line profiles of segments passinglaterally (left to right) through the neck region. The neck is comprisedof muscle, bone, and arteries, but the trachea stands out from all othertissues because it contains only air, which has significantly lessdensity than tissues. The line segments will show where air is locatedand a small region will be identified that contains pixels assigned asair. Image noise in the x-ray image is calculated by subdividing theentire image into smaller patches. Gaussian noise is estimatedindependently for each patch and those with the least amount of noiseare used for texture mapping. The texture mapping technique uses agradient covariance matrix to estimate an initial texture level in eachpatch. A patch with the least initial noise level has the noise levelre-estimated with an iterative process that continues until the noiseestimate for the patch converges with additional iterations of thegradient covariance matrix. A weak textured patch is assumed to belocated in air, wherein the air is residing in a location that is awayfrom the patient, e.g., an upper corner of the x-ray image. Estimationof the patch's noise level gives the baseline noise level throughout theimage. The baseline noise level that the iterative gradient covariancematrix identified is then subtracted from the entire image to obtain thenoise-free air density estimate in the trachea.

The post-processing software 106 overlays a human skeleton model (whichis individually scaled for each patient) onto the surface positionestimate provided by the 3D spatial position localizer 300 in order toestimate the lung's initial location. The individually scaled patientskeleton is rigidly registered to the x-ray image using visiblelandmarks on the surface of the skin (e.g., clavicle, rotator cuff,scapula, vertebrae, etc.). After the skeleton has been rigidlyregistered to the x-ray image, the skeleton provides the position of therib cage. The rib cage itself provides a boundary condition for the edgeof the lungs and for the pixel values close to the trachea's noise-freeair density estimate. Both the edge of the lungs (via the rib cagelocation) and the pixel values close to the trachea's noise-free airdensity estimate are automatically identified by the region growingalgorithm as seed locations (from which the region growing algorithmwill initiate and subsequently grow radially outward from). Regiongrowing is a region-based segmentation method. This approach tosegmentation first identifies a set of initial seed points within animage and then examines neighboring pixels of the initial seed pointsand determines whether the neighboring pixels should be added to theregion. The process is iterated on, in the same manner as general dataclustering algorithms. In other words, region growing algorithms useinitial placement of seed pixels to expand outward using a statisticalprocess that annexes “similar” pixels. The region growing algorithm willcontinue (to annex similar pixels) until the identified pixels arestatistically dissimilar from the annexed cluster.

In practice within the GREX imaging system, the region growing algorithm“stops” (e.g., detects pixel dissimilarity) at important anatomiclandmark interfaces (such as the lungs, which are bounded by the intensepixels of the rib cage). Pixels that the region growing algorithm doesnot identify as belonging to lung tissue will be masked (a mask image isdefined as an image that enhances structures once subtracted from anoriginal image) to form two separate images. Those two separateresulting images are (i) the segmented lungs and (ii) the remaining bodytissues. In order to provide an accurate and noise-free segmented lungvolume that gives the radiologist increased diagnostic visibility (e.g.,a lung volume that is visually unobscured by non-lung tissue), bodymask-related (e.g., non-lung and therefore visually uninformative)tissues are removed from the lung image. For example, the pixelsbelonging to the intercostal muscles within each simulated imaging rayprojection are altogether subtracted from the segmented lung image. Inaddition to the aforementioned subtraction of the body mask from thelung image to yield improved lung tissue visualization, the body maskcan also be used to provide a second check of the 3D spatial positionlocalizer 300's calculated patient surface position. For example, thepost-processing software 106 calculates the number of pixels that theregion growing algorithm identifies as the body mask, and thencalculates the body diameter at various locations along the height ofthe torso. This body diameter calculation should closely agree with the3D spatial position localizer 300's estimate of the patient's bodydiameter. If not, it might indicate that the 3D spatial positionlocalizer 300 needs to be re-calibrated to increase its accuracy.

If a clinical user desires a more accurate view of the body mask (e.g.for clinical or educational reasons), the body mask images are simulatedwith the optimal x-ray unit settings, thereby removing forms of noiseand potential sources of artifacts from the body mask. The body mask andthe segmented lungs could then recombine to form artifact- andnoise-free x-ray images with global enhancement for clinicalapplications like structure contouring.

Section 3.3—Biomechanical Modeling

The biomechanical models used in the post-processing software 106 arecreated from the first principles of physics, namely the law ofconservation of mass and the ideal gas law. The goal of thepost-processing software 106's biomechanical models is to determinebiophysical quantities that enhance a clinician's ability to diagnosedisease. Relevant biophysical quantities include, but are not limitedto, stress and strain of lung tissue elements.

A mechanical system loaded with a force produces stress. In the contextof the lung, an element of a mechanical system is represented by lungtissue. Lung tissue that is visible and distinguishable in medicalimaging consists of parenchyma (including alveoli sacs, alveoli walls,bronchial tubes, and blood vessels). Parenchyma is directly responsiblefor lung function. Suitable tissue elements for biomechanical modelingshould be small enough to be homogeneous inside, but statisticallystable in response to respiratory stimuli. Typical voxel sizes in lungmedical imaging range from 1 mm³ to 3 mm³, which equates to 125 to 375alveoli. The voxels are deemed to be nearly homogeneous in density andcontain enough alveoli to provide a stable response to respiratorystimuli. The alveoli are arranged in hexagonal arrays that inflate dueto distending normal stress from each shared alveolar wall. The sum ofall distending normal stresses within a lung tissue element provides anestimate of the pressure experienced by the alveoli and caused byrespiratory stimuli. The distending stress is counterbalanced by therecoil stress on the alveoli wall, and an equilibrium exists between thetwo stresses when the airflow through the tissue element is 0. Spatialtranslation of a lung tissue element's position, in any one direction,due to changing lung tidal volume can be modeled by the tissue element'smaterial response to normal stress on the lung tissue element'scorresponding face. In other words, the biomechanical model includesvectorized terms that describe the lung tissue element's response toincreasing tidal volume, wherein the vectorized terms relate to normalstress.

Strain is defined as the response of a mechanical system to stress. Fromthe perspective of an element of material (e.g., tissue), stress is adeforming force, and strain is a restoring force. Stress vectors on thelung tissue element's face contains two components: (i) normal stress(related to the lung tissue element's outward or inward directionalmotion which results in either expansion or contraction, respectively),and (ii) shear stress which is perpendicular to the normal stress and iscaused by airflow-induced pressure imbalances. Note that, by definition,the perpendicular component of shear stress does not contribute to lungvolume changes. An illustration of the relationship between normalstress/shear stress and tidal volume/airflow, can be found in the“airflow vs tidal volume” plot depicted in FIG. 10. Exhalation islocated at the lowest tidal volume magnitude where the airflow is 0(left-most point on the curve). During inhalation, the airflow ispositive and the tidal volume is increasing (upper portion of thecurve). When airflow slows, tidal volume reaches its maximum magnitude.As the tidal volume approaches maximum magnitude (right-most point onthe curve), the airflow sharply decreases and the lung increasinglybegins to expel air. As the lung expels more air, the tidal volumebegins to decrease. The tidal volume decreases when the airflow isnegative, and continues to decrease until both the tidal volume reachesresidual capacity and the airflow is zero (e.g., exhalation). Tosummarize, a lung tissue element's motion is defined by the tidal volumeand airflow respiratory stimuli. A lung tissue element's motion iscaused by the normal stress and shear stress acting upon the element.Changes in the lung tissue element's shape (e.g. compression,elongation) are not modeled by stress; rather, an element's shapechanges are modeled by strain.

The model creates a new diagnostic perspective within the field ofmedicine because medical analysis, using the model, is governed byquantitative force analysis. The balance of stress and strain forces ateach voxel in the lung fundamentally assesses lung health because thelung's functional behavior (e.g., lung tissue motion) can now be bothvisualized and analyzed from a clinical perspective.

The first step in building the model is to identify what tissues arepart of the lung and what tissues are not part of the lung. Toaccomplish this task, GREX imaging technology acquires multiplesnapshots of the chest geometry in multiple configurations (6 distinctbreathing phases). The lung is segmented based on region growingsegmentation algorithm using the trachea's air density as an initialstarting point for the region growing algorithm. GREX imaging system 100uses two different deformable image registrations for building thebiomechanical model: one acts on lung tissue and the other acts onnon-lung tissue (e.g. chest wall, ribs, liver, heart, trachea,esophagus, etc.). The results of a region growing algorithm distinguishbetween lung tissue and non-lung tissue prior to the deformable imageregistration step.

The justification for GREX imaging system's using two differentdeformable registrations, one for lung and the other for non-lung, isthat the motion and material properties of lung are different from thoseof non-lung. If just one deformable image registration is used for thetotality of lung and non-lung, the registration would assign a greaterweight to the non-lung tissue compared to the lung tissue. This wouldresult in the lung tissue being assigned an unrealistically low weight,and therefore unrealistically limited extent of motion. GREX imagingtechnology is built to visually elucidate the subtleties of lung motion,including the subtleties of motion at the computationally complex lungsurface.

One deformable image registration algorithm that can track tissuemovement between images is the optical flow algorithm. FIG. 27 is aschematic flow chart of a multi-resolution 3D optical flow algorithm2700 according to some embodiments of the present disclosure.Specifically, the 3D multi-resolution optical flow algorithm performsdeformable image registration which identifies structures in twodifferent images based on each structure's brightness or contrast orboth. To that end, given that the non-lung tissues containcharacteristically brighter (e.g., at least 10× denser) anatomicalstructures (e.g. ribs, pectoral muscles, sternum, etc.) compared to lungtissue, using a single 3D multi-resolution optical flow algorithm onboth non-lung and lung regions would result in the less dense lungtissues being artificially non-prioritized within the algorithm. Thecomputational resources of the algorithm would be preferentiallyallocated to the brighter contrast structures (like the ribs, forinstance) that reside in non-lung tissue. An outcome like this, wherecomputational resource allocation preferentially neglects lung tissuedynamics, is anathema to GREX imaging's purpose of visually elucidatingthe subtleties of lung tissue motion.

Since preferential resource allocation to high contrast structures isinherent to the 3D multi-resolution optical flow algorithm, the task ofdeformable image registration in the chest is divided into two separatesubsidiary tasks (e.g., two internally more homogeneous regions): (i)the image registration of the lung, and (ii) the image registration ofthe non-lung. In some embodiments, to parse the two separate taskregions from the chest as a whole, identification of the lung surface(e.g., the boundary between the lung and non-lung) is required prior tothe 3D multi-resolution optical flow deformable image registration.Identification of the lung surface is fundamentally possible using theregion growing algorithm, which begins inside the lung in air-filled(e.g., visually dark) regions, grows outward towards the lung surfaceboundary, and encounters a high pixel contrast at the lung surfaceboundary. Performing the region growing algorithm is the first step.

The lung is not attached to the chest wall. As a result, the lung'smotion is relatively independent from the chest's motion. In otherwords, instead of a predictable push-pull response at the lung surfaceboundary, there are other types of tissue dynamics at work. For example,a horizontally adjacent chest voxel moves downward vertically, so thelung voxel moves horizontally into the space where the chest voxelpreviously resided.

In order to accurately model the complex motion dynamics, GREX imagingsystem 100 quantifies the shear force that the surfactant layerexperiences at the lung surface boundary. Using two separatesegmentations for lung and non-lung tissue provides the basis of forceestimation. The procedure of force estimation is performed bysubtracting the segmented lung pixels (e.g., remove their assignedvalue) from an x-ray image (performed for each reconstructed breathingphase image). The previously segmented lung will be masked from theoriginal image which provides an image containing all remaining tissues.Each individual image's segmented chest geometry must be registered toeach of the chest geometries of the other images so that the position ofeach lung tissue element is known across all images. Themulti-resolution optical flow algorithm performs the image registrationby calculating a displacement vector field that shows the displacementof every pixel between two images taken at different breathing phases.Indeed, knowing the displacement vector field allows accurate spatialaccounting of all lung tissue elements in the chest geometry.Differences between the segmented lung registration's displacementvector field and the non-lung tissue's displacement vector field providethe magnitude and direction of the shear force that exists between thelung and the chest wall.

Based on observation of over 150 unique patients, the relationshipbetween displacement and tidal volume is linear. The relationshipbetween displacement and airflow is also linear. The multi-resolutionoptical flow algorithm's output is displacement vectors in a coordinatespace for each of the measured tidal volume and airflow magnitudes. Whenthe displacement vectors are calculated for all breathing phases, theresult is a closed loop trajectory (as shown in FIG. 10), which servesas observations for the biomechanical model. As describe below in moredetail, the biomechanical model parameters—which can include parametersthat represent normal stress associated with tidal volume, normal stressassociated with airflow, and shear stress associated with airflow—aresolved using a QR decomposition for each lung tissue element separately.The parameters are specific to each lung tissue element (e.g., each lungtissue element has a unique solution) and collectively describe the lungtissue element's response to respiratory stimuli. The biomechanicalmodel parameters are vectors that are globally scaled by the measuredtidal volume and airflow (e.g., the tidal volume and airflow are scalarvalues). Relationships between the biomechanical model parameters, suchas the angle between two (vectorized) parameters, may aid in diagnosingpotential disease incidence in the lung. Based on the lung tissueelement's unique biomechanical model vector parameters (e.g., each pieceof tissue has different vector parameters), the lung tissue element'sdisplacement is scaled to the chest geometry, wherein the chest geometryis defined by the tidal volume and airflow measurements. Thebiomechanical model may be calculated for each patient or shared bymultiple patients.

In some embodiments, the biomechanical model approximates the motion oflung tissue to be a function of multiple factors, including the lung'stidal volume (T_(v)), airflow (A_(f)), and cardiac phase (H_(c)). Thesevalues are global values, e.g., the cardiac phase is the same for alltissue elements in the chest. Global values are treated as scalarnumbers and are measured by the hardware discussed in Section 1. Notethat the tidal volume, airflow, and cardiac phase are all time varyingmeasurements. The unique stress and strain values for each tissueelement is mathematically expressed by the equation below using thevectors

₁,

₂,

₃, and

₄:

−

₀ =T _(V)

₁ +A _(f)(

₂+

₃)+H _(c)

₄  (2)wherein the

₁ vector describes normal stress caused by tidal volume,

₂ describes normal stress caused by airflow,

₃ describes shear stress caused by airflow, and

₄ describes tissue motion introduced by the perturbing heart motion.Altogether, the displacement (

−

₀) of tissue at any point in a closed loop trajectory is expressed as asummation of the stress, strain, and perturbing heart motion vectorsscaled by the tidal volume, airflow, and cardiac phase respectively.

FIG. 24 depicts an exemplary closed-loop lung tissue motion trajectoryof a piece of tissue located in the left lung, close to the heart,partially caused by the heart's interaction with the lung according tosome embodiments of the present disclosure. Note that the wave behaviordepicted in FIG. 24 arises from the heart's interaction with the lung.FIG. 24 is a schematic block diagram illustrative of how to determinethe position of the piece of lung tissue moving in the closed loop lungtissue motion trajectory based on the aforementioned biomechanical modelaccording to some embodiments of the present disclosure. FIG. 24 showshow the three vectors of the biomechanical model described in theequation above are summed together to calculate the displacement of asingle tissue element from the origin to any location on the closed looptrajectory.

A major advantage of using a physiologically-based, biomechanical modelto interpolate images between acquired breathing phases is the abilityto use quantitative physical quantities to check the accuracy of thebiomechanical model's output results. According to the ideal gas law,the ratio of lung volume change to tidal volume is 1.11 at roomtemperature. In other words, the ratio of room air density to lung airdensity is 1.11. Accordingly, the volume integral of the divergence ofthe normal stress vector should also be 1.11 (e.g., ∫_(V) (

·

₂) dV, where V is the total body volume). The ideal gas law provides a“sanity check”, yielding useful quality assurance information on the 3Dspatial position localizer 300, breathing phase sensor 110, and eachinterpolated image.

An example of how the GREX imaging technology's biomechanical modelingenhances diagnosis is an early stage lung tumor that is not visible to aradiologist's eye at the time of image inspection. The tumor is notvisible to the radiologist because it is too small for the imagingsensitivity. Even though the tumor is not visible to the radiologist,its presence still affects the balance of forces inside the lung since atumor's electron density is greater than healthy lung tissue's electrondensity. The tumor's higher electron density means that the tumor hasdifferent material and mechanical properties (e.g., differentcharacteristic stress and strain parameters) that affect both thetumor's motion and the motion of the local area around the tumor (e.g.,healthy tissue close to the tumor site). The effect of a tumor on thelocal healthy lung tissue can be loosely analogized to the effect masshas on the space-time continuum under the general relativity theory:when a massive object is present, the space-time around the object bendsso that light behaves differently in the object's vicinity compared tothe light's behavior when the mass is absent. The same analogizedprinciple applies in the lung, such that a tumor warps the motiontrajectories of adjacent healthy tissues into moving differentlycompared to a healthy lung's motion trajectories. The biomechanicalmodel's displacement vector map makes changes in lung tissue compositionand biomechanical properties readily apparent to medical practitioners:when a tumor is preset, the displacement vector field shows an unnaturallevel of vector curl and/or other altered properties. GREX imagingtechnology's post-processing software 106's creation of parameter maps,discussed in Section 3.4, visually displays such previously invisible,diagnostically important information for the end-user. GREX imagingtechnology's parameter maps are examples of the new diagnosticperspective that the GREX platform brings to medicine.

FIG. 25 is a schematic flow chart of operations 2500 of components ofthe biomechanical model according to some embodiments of the presentdisclosure.

The biomechanical model's process provides a quantitative means forbiometrically interpolating between two images (2D or 3D) acquired atdifferent breathing phases. Equation (2) shows that the solution for thebiomechanical model is the displacement between two breathing phases (

−

₀). As noted above, the displacement between two breathing phases (

−

₀) is found by performing deformable image registration to index the twobreathing phases to one another, which is typically comprised of thefollowing three steps:

-   -   Step 1: Perform region-based segmentation to delineate the        structural boundary between the lung and non-lung.    -   Step 2: Perform intensity-based structure mapping using 3D        multi-resolution optical flow to match “same” structure in two        separate image cubes.    -   Step 3: In some embodiments, the initial estimate of the        displacement between two breathing phases (        −        ₀) is iteratively refined until it is optimized.

FIG. 26A is a graphic depiction of a lung tissue element's motiontrajectory during a breath cycle according to some embodiments of thepresent disclosure. As shown in FIG. 26A, there are 6 images per imagingangle, corresponding to six respective breathing phases of a completebreathing cycle, from left to right, early inhalation (EI), lateinhalation (LI), maximum inhalation (MI), early exhalation (EE), lateexhalation (LE), and maximum exhalation (ME), as depicted in FIG. 14.According to the finite strain theory, a vector joining the positions ofa particle in the un-deformed configuration and the deformedconfiguration is called the particle's displacement vector. Using aparticular voxel in the EI image cube as a reference, the six imagesillustrate the deformation of the reference voxel from its originalposition, size and shape during the breathing cycle. When the lung isfilled with more and more air, the reference voxel begins to “bubble”.In other words, the lung issue corresponding to the reference voxeldeforms when the voxel “bubbles”. The displacement between two breathingphases (

−

₀) quantifies the extent of voxel bubbling or the deformation of thecorresponding lung tissue. Deformable image registration assumes thatthe reference voxel in the EI image cube moves to its new position inthe LI image cube while deforming at the same time due to the inhalationof more air into the lung tissue. As the breathing cycle moves forward,the reference voxel keeps its motion trajectory as depicted by the MI,EE, LE, and ME image cubes, respectively. In other words, for everyvoxel in the reference image cube, a set of displacement vectors arecomputed across all the six image cubes.

FIG. 26B illustrates that there are 5 deformable registrations (2→1,3→1, 4→1, 5→1, 6→1) between the EI image cube and the other five imagecubes. These six image cubes represent the patient's chest anatomy atthe six corresponding predefined breathing phases. For each voxel, thereis a vector (

) at an image cube corresponding to each of the six breathing phases.Assuming that the vector corresponding to the EI image cube is zero, thesix displacement vectors for a given voxel can be expressed as:[

₁=0,

₂,

₃,

₄,

₅,

₆] or denoted as [

_(n)],wherein the parameter “n” is a time-dependent parameter corresponding toa respective breathing stage.

Similarly, for a particular breathing stage “n”, the biometric datamatrix including the lung's tidal volume (T_(v)), airflow (A_(f)), andcardiac phase (H_(c)) can be expressed as:[T _(v) _(n) ,A _(f) _(n) ,H _(c) _(n) ]^(T) or denoted as [B _(n)].

For each voxel in the image cube, the biomechanical model for theparameter matrix, [

]=[

₁,

₂+

₃,

₄], can be solved for using the six displacement vectors ([

₁=0,

₂,

₃,

₄,

₅,

₆]) and the corresponding biometric data matrixes ([T_(v) _(n) , A_(f)_(n) , H_(c) ^(n)]^(T)) described above. The four vectors describe thevoxel's tissue properties, which govern the voxel's displacement vectorsand deformations. For each voxel in the reference image cube, there is:[

][B _(nd)]=[

_(n)]

As noted above, there are many deformable image registration algorithmscapable of performing image registration for GREX imaging, including the3D multi-resolution optical flow algorithm. The 3D multi-resolutionoptical flow algorithm calculates smooth (e.g., fluid-like) transitionsbetween images that are taken at different observed tidal volumes. Thecalculated displacement between two breathing phases (

−

₀) provides observed points in the tissue trajectory shown in FIG. 24.Once the parameters (

₁,

₂,

₃,

₄) of the biomechanical model are solved for via, e.g., a least-squareregression, varying the tidal volume (T_(v)), airflow (A_(f)), andcardiac phase (H_(c)) produces the entire closed loop trajectory. Takingthe closed loop trajectories for all tissue elements in the chest givesnew image cubes that can be thought of as biometrically interpolated. Asa summary, Table 1 shows each component of GREX's biomechanical modeland how the component is found.

TABLE 1 Summary of GREX's biomechanical model's parameters. ModelComponent Description How it is Found

Coordinates of current image relative The static image cubes are to thereference image deformably registered together

₀ Coordinates of reference image via Optical Flow T_(V) Tidal VolumeFound via a breathing phase sensor 110 A_(f) Airflow Found via abreathing phase sensor 110 H_(c) Heart phase normalized to end- Foundvia heart phase sensor diastole so that 112 H_(c) varies between 0 and 1

₁,

₂,

₃,

₄ Tissue specific motion parameters Found via least squares regression

The post-processing software 106's biometric interpolation betweenacquired image cubes populates all potential breathing phases so that acomplete movie of the chest is created. Generally speaking, a movieneeds at least 30 simulated images to smoothly transition betweenframes. FIG. 28A is a schematic flow chart 2800 illustrative of creatinga movie via biometric interpolation according to some embodiments of thepresent disclosure. As shown in FIG. 28B, it is assumed that thebiometric data matrix corresponding to the EI image cube is:T _(v)=20 ml,(A _(f))=20 ml/s, and H _(c)=0.10.

For each voxel in an interim simulated image cube at a particular momentof the breathing cycle, e.g., EI+Δt, EI+2Δt, EI+3Δt, etc., can becalculated using the biomechanical model for the parameter matrix, [

], and a corresponding biometric data matrix for the particular moment.

Section 3.4—Parameter Maps

One of the clinical benefits of GREX imaging technology is the uniqueparameter maps. Using 2D plots, 2D color washes, 3D plots, and 3D vectorfield maps, the GREX imaging technology presents the end-user withpreviously unavailable information on the patient's chest health.

FIG. 29 depicts an example of a healthy patient's standard radiograph(left) and an example of a standard radiograph for a patient with astage 1b left upper lung tumor (right as indicated with the arrow). Bothfigures show a standard radiograph that is currently used by theradiography field. Although the diseased left lung in the right side ofFIG. 29 is an early stage lung tumor, it is not readily visible in thestandard radiograph because the standard radiographs are difficult toread and only show anatomic information. In contrast, FIG. 30 depictsthe accompanying GREX parameter maps showing indicators of the same twopatients' health situation according to some embodiments of the presentdisclosure. The parameter maps on the right side clearly indicate thatthe patient has disease in the left upper lung while the standardradiograph is ambiguous. Changing the window level and image contrasteventually shows a poorly ventilated region of the left upper lung.However, if the end-user does not take these steps, the chance ofcatching this early stage lung cancer tumor is low. In other words, theGREX generated parameter maps can greatly reduce the change of anend-user's risk of a missing disease.

First, let's consider the 2D color map

₁ in FIG. 30, which describes normal stress with respect to tidalvolume. Based on the definition of

₁, the end user would expect that the magnitude of

₁ will be greater near the diaphragm compared to the apex of the lung(e.g., the diaphragm has greater tissue displacement than the apex ofthe lung when tidal volume is increased). Generally speaking, themagnitude of

₁ varies smoothly throughout a healthy lung. If the gradient

f was calculated across the lung, the result would be a smooth function.The examples depicted in FIG. 30 show that, for both patients, althoughthe

₁ parameter is similarly distributed, the healthy patient has twice thetissue displacement as the sick patient.

Next consider the 2D color wash of (

₂+

₃), which represents the sum of normal and shear stress associated withairflow. Generally speaking, higher parameter magnitudes occur close toregions where the bronchial tree brings air into the lung at a fasterrate (mid-lung). But in a diseased lung, the presence of a tumor maysubstantially change the behavior of the lung's elasticity substantiallysuch that the tumor may be visually distinguishable from thefunctionally healthy lung tissue distribution. In the examples shown inFIG. 30, the presence of a lung tumor is clearly visible in the leftlung because of the significant difference in magnitude. When diseaseaffects a lung region, other lung tissue regions “pick up the slack” byventilating healthy regions rather than diseased regions. But as shownin the left side figures of FIG. 29, the healthy lung is more elasticthan the diseased lung. In other words, airflow resistance was greatlyincreased in the position where the tumor is located, therebyhighlighting the tumor's presence and providing quantitative analysis onthe tumor's effect on the patient's ability to properly ventilate duringrespiration. The ratio between the parameter associated with tidalvolume and the parameters associated with airflow dramatically showsthat the left upper lung has a considerably different pattern than thehealthy patient. Physically, higher percentages are interpreted as thetissue moving in a more circular pattern than the example tissuetrajectory shown in FIG. 24. The histograms of the total observed motioncomponent attributed to tidal volume (T_(V)

₁) and airflow (A_(f) (

₂+

₃)) located below the 2D color washes also displays a clear indicator ofdisease in the left lung. Healthy lungs have a bimodal distribution ofA_(f)(

₂+

₃) but when disease is present in one lung, the overall distributionpattern is different in both lungs. GREX imaging technology may involveBayes processes to leverage patient interviews (information voluntarilyprovided by the patient before the exam) with the distribution of thebiomechanical model's parameter histograms to better classify diseaseetiology. In sum, consistent indicators of lung disease (e.g., of atumor's presence, as shown in FIG. 30) across multiple new GREXparameters greatly aids in early detection and disease diagnosis.

Section 3.5—Diagnostic Disease Pointers

Lung cancer, chronic obstructive pulmonary disease (COPD), lowerrespiratory tract infection, and tuberculosis all have disease pointersthat may be visible in existing digital diagnostic x-ray imaging.However, diagnostic disease pointers are not always visible at earlydisease stages. But as shown in FIGS. 29 and 30, the GREX parametershave the potential of serving as diagnostic disease pointers at earlydisease stages. If the healthcare team only considered the standardradiographs the lung cancer presence may not have been detected becausethe lung cancer tumor is not large enough to clearly present in thestandard radiograph. GREX imaging uses biometric signals in conjunctionwith multiple biometrically-targeted radiographs to leverage previouslyunavailable information on how the lung moves to diagnose disease. TheGREX process directly addresses the problem with early lung cancer, thatlung cancer tends to have poor specificity in digital diagnostic x-rayimages. The existing sensitivity limitations of digital diagnosticx-ray-based diagnoses is addressed through biometrically-informedimaging using the patient's unique and disease indicating breathinginformation. Clinicians can observe diagnostic insights as early asdisease onset and continue monitoring the patient as the diseaseprogresses through lung tissue motion visualization and the parametermaps. Machine learning and finite element analysis techniques will beapplied to discover subtle patterns or base-line changes in lungfunction to assist the ability of an end-user to detect disease at thevery onset giving patients higher survival chances and more options fortreatment.

Another diagnostic example of where GREX would disrupt the diagnosticcommunity is in classifying lung disease etiology. The presentation ofasbestos caused lung disease and cigarette caused lung disease aredifferent in biopsies. Asbestos is a naturally silicate minerals thatconsists of long, thin fibrous crystals, composed of millions ofmicroscopic fibers. Inhaled asbestos fibers penetrate the alveoli andeventually forms a dense web that compromises the alveolar functionwhich decreases lung function. The dense webs collect cancerous tissuesand is named mesothelioma. Standard radiographs can only identifymesothelioma by the plaque buildup, which presents as denseconsolidation (fuzziness) in the lung image. GREX may detect the subtlepresence of asbestos through the parameter maps before an end-user couldvisually identify the presence of asbestos. As the web if asbestos isforming, the elasticity of the lung is reduced locally. The small localreduction in elasticity will be visible in the parameter maps (2D colorwashes, parameter ratios, and histograms). For example, in tissue thathas lost elasticity, the tissue's trajectory during breathing will bemore circular than elliptical. This means that the ratio between the

₁ and (

₂+

₃) magnitudes would be higher than healthy tissue. Consulting the colormap would clearly show a region of the lung that is displaying a patternindicative of disease.

Inhaled particles (non-fiber) would display completely differently thanthe fibrous asbestos particles. Inhaled particles deposit within thelungs, reducing lung function by “clogging” airways, forming scartissue, and forming tumors but not webs. GREX will show the beginning ofparticulate deposition by detecting minute local changes in lung motiondynamics that are inconsistent with healthy characteristics. Cigarettescontain tar and radon, which adhere to the alveoli and drasticallychanges lung function. GREX can track the reducing lung function andgive end-users a unique tool to better demonstrate to a patient howdestructive the smoking habit is. COPD is another disease that can beelucidated with parameter maps more effectively than the currentclinical methods. COPD is currently detected with spirometry testing andstandard radiography. Neither of these methods are particularlysensitive and do not detect COPD at the earliest onset. Detectingdisease at the earliest possible time can give patients more opportunityto take advantage of preventative medicine and change bad habits beforethe it is too late.

Section 3.6—Movie Presentation

The point of the movie presentation graphic user interface (GUI) is toprovide a clean and intuitive canvas for displaying the planar movie and3D movie results. All functions like rotate view, pause movie, and rulerare placed into bins that are represented with tabs across the top ofthe screen. Selecting a function changes the tooltip to show the userwhat function is in use. The GUI is designed to be light weight so thatthe GUI will function even with older computer systems. Finally, themovie presentation GUI will work in conjunction with theannotation/contouring, possible disease pointers, and cloud computingplatform.

Medical personnel end-users prefer to directly highlight and place noteson medical images rather than attaching additional documents to theimages. Medical end-users clamor for the ability to include imageannotation (“attention-grabbing” arrows and treatment notes) andanatomic contouring (drawing a virtual line around an anatomicstructure) to imaging studies. Medical end-users are often members oflarge, multi-disciplinary care teams that collaboratively treat apatient. The following example describes the current workflow andtechnological capabilities of a clinical care team:

Once an imaging study is performed on a lung cancer patient, the imageis read by a radiologist, prescribed radiation treatment orders by aradiation oncologist, and used as a basis for surgical intervention byan operating surgeon. Specifically, the radiologist draws a contouraround the tumor site and passes the contoured image to a radiationoncologist.

The radiation oncologist then writes instructions for the radiationtreatment and/or tumor resection surgery based on the image.

Using the radiology contour and the radiation oncology tumor resectioninstructions, the surgeon resects the tumor.

The post-processing software 106 provides tools for end-users toannotate and contour directly on the moving images, which streamlineshealthcare workflow. This user-friendly capability enhances healthcareworkflow and reduces the probability of medical mistakes. Theinteractive nature of our user interface means that treatmentinstructions and/or medical concerns are now plainly visible to allusers, and the relevant clinical notes are displayed correctly in thecorresponding anatomical region of interest.

FIGS. 31A-31B are flow charts illustrating a method 3100 of imaging apatient's lung. In some embodiments, any or all of the operationsdescribed below can be performed without human intervention (e.g.,without intervention by a technician). In some embodiments, method 3100is performed by or using any of the apparatuses described herein (e.g.,the GREX imaging system 100 shown in FIG. 1). Some operations of method3100 are performed by a computer system that includes one or moreprocessors and memory storing instructions which, when executed by theone or more processors, cause the one or more processors to perform theoperations of method 3100. Some operations in method 3100 are,optionally, combined and/or the order of some operations is, optionally,changed.

The method includes positioning (3102) the patient at a firstorientation relative to an x-ray imaging apparatus (e.g., GREX imagingsystem, FIG. 1). In some embodiments, method 3100 is performed at alegacy medical imaging system that is modified to perform certainoperations described below. In some embodiments, positioning the patientat the first orientation includes moving (e.g., rotating) the patient tothe first orientation (e.g., as discussed with reference to FIG. 35),while the x-ray imaging system (e.g., the x-ray unit and detector panel)remain at a fixed position. For example, in some embodiments, thepatient is seated in or standing on a patient positioning fixture (PPF),such as PFF 3501 described with reference to FIG. 35. In someembodiments, positioning the patient at the first orientation relativeto the x-ray imaging apparatus includes rotating the patient positioningfixture. For example, in some embodiments, at the beginning of method3100, the patient positioning fixture is rotated such that the sagittalplane of the patient is positioned at a predefined angle with respect toan optical axis of the x-ray imaging apparatus (e.g., an axis alongwhich the x-ray imaging apparatus transmits x-rays). In someembodiments, the predefined angle is selected from the group consistingof −45 degrees, −22.5 degrees, 0 degrees, 22.5 degrees, and 45 degrees.

In some embodiments, positioning the patient at the first orientationincludes moving (e.g., rotating) the x-ray imaging system, while thepatient remains at a fixed position (e.g., as discussed with referenceto FIG. 17).

In some embodiments, while the patient is positioned at the firstorientation relative to the x-ray imaging apparatus, the patientpositioning fixture maintains the patient in a fixed position (e.g.,stabilizes the position of the patient) such that three-dimensionalimages of the patient's lung can be reconstructed (e.g., as describedthroughout this disclosure) based on a “stationary object” assumption.

The method includes obtaining (3104) a volumetric measurement of apatient's breathing (e.g., as the patient is breathing normally; thepatient need not hold his or her breadth). In some embodiments, thevolumetric measurement of the patient's breathing is a measurement(e.g., a direct measurement) of the patient's lung volume (e.g.,instantaneous lung volume) or a derivative of the patient's lung volume(e.g., a flow-rate). In some embodiments, as explained in greater detailbelow, the volumetric measurement of the patient's breathing is ameasurement that can be converted to the patient's tidal volume (e.g.,by measuring chest rise and fall). The term tidal volume, as usedherein, means a difference between a current lung volume and apredefined baseline (e.g., a volume during maximum exhalation of anormal breath without extra effort applied, a volume during maximuminhalation of a normal breath without extra effort applied, or any othersuitable fiducial volume).

In some embodiments, the volumetric measurement of the patient'sbreathing is a geometrical (spatial or positional) measurement of thepatient's breathing.

In some embodiments, the volumetric measurement of the patient'sbreathing includes (3106) a measurement of the patient's chest rise(and/or chest fall). In some embodiments, the volumetric measurement ofthe patient's breathing is obtained using (3108) one or more volumetricbreathing phase sensors (e.g., breathing phase sensor 110, FIG. 1) ofthe group consisting of: a three-dimensional (3D) scanner, a spirometer,and an abdominal belt. In some embodiments, the method further includescreating (3110) a point cloud of a surface of the patient's chest. Thevolumetric measurement of the patient's breathing is determined from thepoint cloud of the surface of the patient's chest.

In some embodiments, the 3D point cloud is used to determine thevolumetric measurement of the patient's breathing without generating amesh reconstruction of the patient's chest (e.g., the raw output of the3D point cloud is used to generate the volumetric measurement of thepatient's breathing without first generating a mesh). In someembodiments, the point cloud of the surface of the patient's chest isobtained using (3112) a 3D imaging technique to measure one or morepositions of the patient's chest. For example, the 3D imaging techniquecomprises a laser scanning technique such as light detection and ranging(LIDAR). Such laser scanning techniques are beneficial because somelasers can accurately measure positions of the patient's chest evenwhile the patient is wearing a modesty garment (e.g., the patient dons aLIDAR-transparent garment while undergoing method 3100).

In some embodiments, the method 3100 further includes identifying (3114)one or more anatomical landmarks on the surface of the patient's chest(e.g., externally-visible landmarks, such as a clavicle, trachea,sternal notch, sternum, xiphoid process, spine, or humorous) using thepoint cloud of the surface of the patient's chest. The method furtherincludes inferring a location of one or more internal anatomicallandmarks within the patient's chest from the point cloud of the surfaceof the patient's chest (e.g., a location of the patient's lung). In someembodiments, the method includes generating a reconstruction of thepatient (e.g., a generating a computer model for the patient, alsoreferred to as a “virtual patient”). In some embodiments, generating thereconstruction of the patient includes generating a reconstruction ofthe internal anatomy of the patient. In some embodiments, thereconstruction of the internal anatomy of the patient includes acomputer model (e.g., a 3D model) of tissue densities. In someembodiments, the reconstruction includes or is used to determineabsorption cross-sections (e.g., x-ray absorption cross-sections) at aplurality of locations within the body. In some embodiments, thereconstruction of the patient is used to determine an x-ray dose to bedelivered (e.g., for each image) by the x-ray imaging apparatus.

The method includes, while the patient is positioned at the firstorientation relative to the x-ray imaging apparatus, and while obtainingthe volumetric measurement of the patient's breathing, determining(3116), based on the volumetric measurement of the patient's breathing,a breathing phase of the patient (e.g., in real-time, as the patient isbreathing normally). In some embodiments, the breathing phase of thepatient is defined by the volume of the lung. Thus, in some embodiments,determining a breathing phase of the lung includes determining a volumeof the lung.

In some embodiments, operations 3102 et seq. are performed as part of animaging period of method 3100. Method 3100 further includes, prior tothe imaging period, undergoing a training period during whichinformation about the patient's normal breathing is obtained. Forexample, during the training period, volumetric measurements of thepatient's breathing are obtained at regular intervals over a pluralityof cycles of the patient's breathing (e.g., 15, 20, 50 cycles of thepatient's breathing, each corresponding to one breath). The volumetricmeasurements from the training period are then used to associatespecific volumetric measurements with specific breathing phases. Forexample, a volumetric measurement corresponding to a tidal volume of 400ml may be associated with maximum inhalation, a volumetric measurementcorresponding to a tidal volume of 0 ml may be associated with maximumexhalation, and so on. In addition, statistics about the patient'sbreathing (e.g., a histogram) can be obtained during the trainingperiod, and used to verify that breaths taken during imaging are“normal” breaths (e.g., not overly deep breaths or otherwise anomalousbreaths).

During the imaging period, in some embodiments, the breathing phase ofthe patient that is determined is (3118) a future (e.g., predicted)breathing phase. That is, in some embodiments, determining, based on thevolumetric measurement of the patient's breathing, the breathing phaseof the patient includes forecasting the future breathing phase from oneor more current and/or past breathing phases. For example, theforecasting is based on a time-series of breathing phases. In someembodiments, forecasting the future breathing phase from the one or morecurrent and/or past breathing phases includes generating anautoregressive integrated moving average (ARIMA) model. In someembodiments, the forecasting uses data from the training period.

The method includes, in accordance with a determination that thebreathing phase of the patient matches a predefined breathing phase(e.g., that the volume of the lung matches a predefined lung volume),gating (3120) the x-ray imaging apparatus to produce an x-ray projection(sometimes called a projection image) of the patient's lung. In someembodiments, an x-ray projection is an image taken at a particular angle(e.g., determined by the orientation of the patient with respect to thex-ray imaging apparatus). In some embodiments, an x-ray projection isobtained using a single x-ray exposure. In some embodiments, the methodincludes, in accordance with a determination that the breathing phase ofthe patient does not match a predefined breathing phase, forgoing gatingthe x-ray imaging apparatus (e.g., forgoing exposing the patient tox-ray radiation).

In some embodiments, the method includes determining, from thevolumetric measurement of the patient's breathing, whether a currentbreath is an irregular breath. The method further includes, inaccordance with a determination that the current breath is an irregularbreath, forgoing gating (e.g., obtaining) the x-ray imaging apparatus(e.g., continuing to wait for a suitable breath at which to obtain thex-ray projection for the breathing phase).

In some embodiments, the predefined breathing phase is (3122) a firstpredefined breathing phase of a plurality of predefined breathingphases. In some embodiments, the method further includes, whileobtaining the volumetric measurement of the patient's breathing, inaccordance with a determination that the breathing phase of the patientmatches any of the plurality of predefined breathing phases, gating thex-ray imaging apparatus to produce a respective x-ray projection of thepatient's lung. In some embodiments, x-ray projections (e.g., x-raymeasurements) of the patient's lung are not obtained (3124) except whenthe breathing phase of the patient, as determined by the volumetricmeasurement of the patient's breathing, matches one of the plurality ofpredefined breathing phases, thus lowering the total amount of x-rayexposure of the patient.

In some embodiments, the plurality of predefined breathing phasesincludes (3126) an early exhalation phase, a late exhalation phase, amaximum exhalation phase, an early inhalation phase, a late inhalationphase, and a maximum inhalation phase of a complete breathing cycle ofthe patient (e.g., as shown and described with reference to FIG. 14). Insome embodiments, an x-ray projection is obtained for each of theplurality of predefined breathing phases while the patient is positionedat the first orientation relative to the x-ray imaging apparatus.

In some embodiments, the x-ray projection is (3128) a first x-rayprojection and the method further includes repositioning the patient toa second orientation relative to the x-ray imaging apparatus (e.g., byrotating the patient or rotating the x-ray imaging system). In someembodiments, the method includes, while the patient is positioned at thesecond orientation relative to the x-ray imaging apparatus, and whilecontinuing to obtain the volumetric measurement of the patient'sbreathing, continuing to determine, based on the volumetric measurementof the patient's breathing, a breathing phase of the patient. In someembodiments, the method includes, in accordance with a determinationthat the breathing phase of the patient matches the predefined breathingphase, gating the x-ray imaging apparatus to produce a second x-rayprojection of the patient's lung.

In some embodiments, the method further includes generating a staticimage cube, corresponding to the predefined breathing phase, using thefirst x-ray projection and the second x-ray projection (e.g., asdescribed with reference to FIGS. 21A-21B). In some embodiments, astatic image cube is a three-dimensional reconstruction of a volume ofthe patient's lung. In some embodiments, an x-ray projection is obtainedfor each of the plurality of predefined breathing phases while thepatient is positioned at each of a plurality of orientations (includingthe first orientation and the second orientation) relative to the x-rayimaging apparatus. In some embodiments, the plurality of orientationsincludes at least 5 orientations (e.g., −45 degrees, −22.5 degrees, 0degrees, −22.5 degrees, and 45 degrees). In some embodiments, theplurality of orientations includes more than 5 orientations (e.g., 6, 7,8, or more orientations). In some embodiments, x-ray projections are notobtained except for each of the plurality of predefined breathing phaseswhile the patient is positioned at each of a plurality of orientations(including the first orientation and the second orientation) relative tothe x-ray imaging apparatus. Thus, when x-ray projections are obtainedat five orientations and for six different breathing phases, a total ofthirty x-ray projections are obtained (e.g., the x-ray imaging apparatusis gated, as described above, to obtain only these images).

As described elsewhere in this document, these thirty x-ray projectionscan be used to reconstruct a biomechanical model of how the lung movesin 3D. In some embodiments, the static image cube (e.g., as describedwith reference to FIGS. 21A-21B), corresponding to the predefinedbreathing phase, is generated using (3130) less than ten x-rayprojections obtained from various angles at the predefined breathingphase.

One of skill in the art will recognize that method 3100 can be appliedto other types of movement besides lung motion due to breathing. Forexample, in some embodiments, a method includes positioning a patient ata first orientation relative to an x-ray imaging apparatus. The methodfurther includes obtaining a 3D measurements of a portion of thepatient's body (e.g., a 3D measurement of a location of the portion ofthe patient's body). The method further includes, while the patient ispositioned at the first orientation relative to the x-ray imagingapparatus, and while obtaining the 3D measurements of the portion of thepatient's body: determining, based on the 3D measurements of the portionof the patient's body, that triggering criteria are met for triggeringexposure to radiation by the x-ray imaging apparatus; and in accordancewith a determination that the triggering criteria are met, gating thex-ray imaging apparatus to produce an x-ray image of the patient. Insome embodiments, the x-ray image is an image of the portion of thepatient's body (e.g., the patient's leg, abdomen, skull, etc.). In someembodiments, the triggering criteria include a criterion that is metwhen the 3D measurement of the portion of the patient's body indicatesthat the portion of the patient's body is at a predefined location(e.g., with respect to the imaging apparatus). In some embodiments, themethod includes, in accordance with a determination that triggeringcriteria are not met, forgoing gating the x-ray imaging apparatus (e.g.,forgoing exposing the patient to x-ray radiation). Furthermore, in someembodiments, method 3100 is applicable to other types of imaging thatare not strictly based on x-rays, for example positron emissiontomography (PET) imaging or MRI imaging.

In addition, it should be understood that method 3100 can be applied toradiation therapy as well as radiation imaging. For example, in someembodiments, a method includes positioning a patient at a firstorientation relative to a radiation therapy source. The method furtherincludes obtaining a 3D measurements of a portion of the patient's body(e.g., a 3D measurement of a location of the portion of the patient'sbody). The method further includes, while the patient is positioned atthe first orientation relative to the radiation therapy source, andwhile obtaining the 3D measurements of the portion of the patient'sbody: determining, based on the 3D measurements of the portion of thepatient's body, that triggering criteria are met for triggering exposureto radiation by the radiation therapy source; and in accordance with adetermination that the triggering criteria are met, gating the radiationtherapy source to expose the patient to radiation (e.g., expose theportion of the patient's body to radiation). In some embodiments, thetriggering criteria include a criterion that is met when the 3Dmeasurement of the portion of the patient's body indicates that theportion of the patient's body is at a predefined location (e.g., withrespect to the imaging apparatus). In some embodiments, the methodincludes, in accordance with a determination that triggering criteriaare not met, forgoing exposing the patient to radiation.

It should be understood that the particular order in which theoperations in FIGS. 31A-31B have been described is merely an example andis not intended to indicate that the described order is the only orderin which the operations could be performed. One of ordinary skill in theart would recognize various ways to reorder the operations describedherein. Additionally, it should be noted that details of other processesdescribed herein with respect to other methods described herein are alsoapplicable in an analogous manner to method 3100 described above withrespect to FIGS. 31A-31B. Such process are described, for example, withreference to FIG. 2, FIG. 6, FIG. 8, FIG. 11, FIG. 13, FIG. 15, FIGS.21A-21B, FIG. 23, FIG. 25, FIG. 27, FIGS. 28A-28B, FIGS. 32A-32B, FIGS.33A-33C, and FIGS. 34A-34C. For brevity, these details are not repeatedhere.

FIGS. 32A-32B are flow charts illustrating a method 3200 for gating aradiation source at coincidence of a patient's breathing phase andcardiac phase. In some embodiments, any or all of the operationsdescribed below can be performed without human intervention (e.g.,without intervention by a technician). In some embodiments, method 3200is performed by or using any of the apparatuses described herein (e.g.,the GREX imaging system 100 shown in FIG. 1). Some operations of method3200 are performed by a computer system that includes one or moreprocessors and memory storing instructions which, when executed by theone or more processors, cause the one or more processors to perform theoperations of method 3200. Some operations in method 3200 are,optionally, combined and/or the order of some operations is, optionally,changed.

The method includes positioning (3202) the patient at a firstorientation relative to a radiation source. In some embodiments, theradiation source is (3204) an x-ray imaging apparatus. In someembodiments, the radiation source is (3206) a radiation therapy source.For example, as shown in FIG. 3 and FIG. 35, the patient (e.g., patient3502) is positioned in a first position relative to radiation source3504 (e.g., an x-ray unit 108). In some embodiments, as described withreference to operation 3102 (FIG. 31A), positioning the patient includesmoving (e.g., rotating) the patient, whereas in some embodimentspositioning the patient includes moving (e.g., rotating) the x-rayapparatus (e.g., the x-ray source and detector).

The method includes obtaining (3208) a measurement of the patient'sbreathing (e.g., using a breathing phase sensor). In some embodiments,the measurement of the patient's breathing is a volumetric measurementof the patient's breathing, described above with reference to operation3104 (FIG. 31A). In some embodiments, the measurement of the patient'sbreathing is a non-volumetric measurement of the patient's breathing(e.g., a timing-based measurement of the patient's breathing).

The method includes obtaining (3210) a measurement of the patient'scardiac function. In some embodiments, one or more sensors are used(3304) for measuring the patient's cardiac function. In someembodiments, an electrocardiogram (ECG) is used for measuring thepatient's cardiac function (e.g., a 3-lead or a 12-lead ECG). In someembodiments, the method includes obtaining a plurality of measurementsof the patient's cardiac function that provides a time-series ofelectrical signals that control movement of the patient's heart.

Returning to the imaging phase, the method includes, while the patientis positioned at the first orientation relative to the radiation sourceand while obtaining the measurement of the patient's breathing (3212),determining (3214), from the measurement of the patient's breathing, abreathing phase of the patient and determining (3216), from themeasurement of the patient's cardiac function, a cardiac phase of thepatient (e.g., in real-time). For example, in some embodiments, thecardiac phase of the patient is determined using a zero instruction setcomputer (ZISC) processor, as described with reference to FIG. 36. TheZISC processor is capable of identifying, within a single cardiac cycleor fraction of a cardiac cycle, that a predefined landmark in thecardiac cycle has occurred (e.g., the S-wave or T-wave).

In some embodiments, the method further includes, before gating theradiation source to expose the patient to radiation (operation 3222,below), obtaining (3218) measurements of the patient's cardiac functionfrom a plurality of cardiac cycles of the patient. In some embodiments,the method includes, using the measurements of the patient's cardiacfunction from the plurality of cardiac cycles, determining an averageinterval between a predefined cardiac phase and a beginning of thepredefined window of the cardiac cycle. For example, the predefinedwindow of the cardiac cycle represents the interval between the top ofthe R wave and the beginning of the gating window. For example, in someembodiments, operations 3202 et seq. are performed as part of an imagingperiod of method 3200. Method 3200 further includes, prior to theimaging period, undergoing a training period during which informationabout the patient's cardiac function is obtained. For example, duringthe training period, ECG measurements of the patient's cardiac functionare obtained at regular intervals over a plurality of cardiac cycles(e.g., 15, 20, 50 cardiac cycles, where one cycle corresponds to onecomplete period of heart motion, such as from one T-wave to the nextT-wave). The ECG measurements from the training period are then used topredict quiescent periods of heart movement during the imaging phase, asdescribed below.

In some embodiments, the measurements from the plurality of cardiaccycles of the patient are (3220) waveform measurements (e.g., ECGmeasurements) of the plurality of cardiac cycles and the method includesvalidating, as statistically stable, the waveform measurements of theplurality of cardiac cycles.

The method further includes gating (3222) the radiation source to exposethe patient to radiation based on a determination that the breathingphase of the patient matches a predefined breathing phase and adetermination that the cardiac phase of the patient matches a predefinedwindow of the cardiac cycle. In some embodiments, when the radiationsource is gated, the patient's lung is exposed to radiation. In someembodiments, the predefined cardiac window corresponds to a quiescentperiod of heart movement (e.g., a period of time during the cardiaccycle during which the heart movement is minimal, as described withreference to FIG. 12). In some embodiments, the radiation source isgated within the same cardiac cycle as the determined cardiac phase. Inthis manner, by gating the exposure of the patient's lung based on acoincidence of breathing phase and a predefined cardiac phase window, aprecise area of the lung (e.g., a precise region of lung tissue) isexposed to radiation without perturbation or motion due to heartmovement.

In some embodiments, the radiation source is an x-ray imaging apparatus.Gating the radiation source to expose the patient to radiation comprises(3224) gating the x-ray imaging apparatus to produce an x-ray projectionof the patient's lung. In some embodiments, as described with referenceto method 3100, FIGS. 31A-31B, x-ray projections can be obtained in thismanner for a plurality of orientations of the patient with respect tothe x-ray imaging source and a plurality of breathing phases. Thesex-ray projections can then be used to produce a movie of lung motionand/or a biophysical model of the lung (e.g., by relating motion of lungtissue to biophysical parameters, such as stress, strain, elasticity andso on). In some embodiments, in accordance with method 3200, theseimages are acquired within the predefined cardiac window, to minimizeperturbation or motion of the lung due to heart movement.

In some embodiments, the radiation source is a radiation therapy source.Gating the radiation source to expose the patient to radiation comprises(3226) gating the radiation therapy source to irradiate a region of thepatient's lung at a therapeutic dose. In these circumstances, it isimportant to provide as much of the radiation dose as possible todiseased tissue (e.g., cancerous tissue), and as little as possible tohealthy tissue. Method 3200 improves radiation therapy devices bydelivering more accurate doses to diseased tissue while minimizingradiation provided to healthy tissue.

In some embodiments, determining that the cardiac phase of the patientmatches the predefined window of the cardiac cycle includes predicting(3228) the predefined window of the cardiac cycle by, in real-time,detecting (e.g., using BEMP card shown in FIG. 36) the predefinedcardiac phase and waiting a length of time corresponding to the averageinterval between the predefined cardiac phase and the beginning of thepredefined window of the cardiac cycle. For example, in someembodiments, a peak of the T-wave is detected and an average intervalfrom the T-wave to the ideal gating window is waited, at which point theradiation source is gated.

It should be understood that the particular order in which theoperations in FIGS. 32A-32B have been described is merely an example andis not intended to indicate that the described order is the only orderin which the operations could be performed. One of ordinary skill in theart would recognize various ways to reorder the operations describedherein. Additionally, it should be noted that details of other processesdescribed herein with respect to other methods described herein are alsoapplicable in an analogous manner to method 3100 described above withrespect to FIGS. 32A-32B. Such process are described, for example, withreference to FIG. 2, FIG. 6, FIG. 8, FIG. 11, FIG. 13, FIG. 15, FIGS.21A-21B, FIG. 23, FIG. 25, FIG. 27, FIGS. 28A-28B, FIGS. 31A-31B, FIGS.33A-33C, and FIGS. 34A-34C. For brevity, these details are not repeatedhere.

FIGS. 33A-33C are flowcharts of a method 3300 for generating a model ofmechanical properties of lung by fitting data from registered images, inaccordance with some embodiments. In some embodiments, any or all of theoperations described below can be performed without human intervention(e.g., without intervention by a technician). In some embodiments,method 3300 is performed by or using any of the apparatuses describedherein (e.g., the GREX imaging system 100 shown in FIG. 1). Someoperations of method 3300 are performed by a computer system thatincludes one or more processors and memory storing instructions which,when executed by the one or more processors, cause the one or moreprocessors to perform the operations of method 3300. Some operations inmethod 3300 are, optionally, combined and/or the order of someoperations is, optionally, changed.

The method includes extracting (3302) multiple displacement fields oflung tissue from the multiple x-ray measurements (e.g., x-ray images,also referred to as x-ray projections) corresponding to differentbreathing phases of the lung. Each displacement field representsmovement of the lung tissue from a first breathing phase to a secondbreathing phase and each breathing phase has a corresponding set ofbiometric parameters. In some embodiments, the x-ray measurements arex-ray projections (also called x-ray projection images) obtained inaccordance with method 3100 and/or method 3200. In some embodiments,extracting displacement fields from the lung tissue includes identifyinga portion of lung tissue in one or more first x-ray projections from afirst breathing phase as corresponding to the same portion of lungtissue in one or more second x-ray projections from to a secondbreathing phase, and determining the displacement of the portion of lungtissue from the first breathing phase to the second breathing phase(e.g., as described with reference to FIG. 28B). In some embodiments,the identifying is performed using a deformable image registrationalgorithm, as discussed above.

In some embodiments, the multiple x-ray measurements comprise multiplex-ray images, including an x-ray image obtained for the first breathingphase for each of a plurality of orientations of an x-ray imagingapparatus with respect to the patient, thereby forming a plurality ofx-ray images corresponding to the first breathing phase and a pluralityof x-ray images corresponding to the second breathing phase. In somecircumstances, at least one of the x-ray images corresponding to thefirst breathing phase was obtained during from a different breathingcycle of the patient than a different x-ray image corresponding to thefirst breathing phase (e.g., the images were obtained during the samephase, but different breaths). In some embodiments, the method includesgrouping the multiple x-ray images by breathing phase.

In some embodiments, the method includes extracting multiple vectorfields, for which displacement fields are one example.

In some embodiments, one or more sensors are used (3304) for measuringbiometric signals of the patient as one or more sequences of timeseries, including one or more of a 3D spatial position localizer (e.g.,3D spatial localizer 300, FIG. 3), a breathing phase sensor, and acardiac phase sensor. In some embodiments, the 3D spatial positionlocalizer is configured (3306) for measuring the patient's real-timebody movement caused by respiration and heartbeats and outputting themas time series. In some embodiments, the breathing phase sensor isconfigured (3308) for measuring one or more physiologic metrics relatedto the patient's breathing, including a tidal volume and its first-ordertime derivative. In some embodiments, the cardiac phase sensor isconfigured (3310) for measuring periodic and stationary electricalsignals generated by the patient's heart (e.g., an ECG signal). Forexample, the cardiac phase sensor measures periodic and stationaryelectrical signals with characteristic features that correspond to theheartbeat phase.

In some embodiments, the biometric signals of the patient measured bythe one or more sensors are used for triggering (3312) an x-ray unit toacquire an x-ray image of the patient at a specific breathing andcardiac phase (e.g., as described with reference to method 3200).

In some embodiments, the x-ray unit includes (3314) a clock and thebiometric signals of the patient measured by the one or more sensors aresynchronized with the x-ray unit's clock. In some embodiments,respective values of the biometric signals are recorded to be associatedwith the acquired x-ray image.

In some embodiments, the biometric signals of the patient measuredduring a training window are used (3316) for building an optimizedbreathing prediction model for predicting a desired breathing phase atwhich an x-ray unit is triggered to capture an x-ray image of thepatient.

The method includes calculating (3318) one or more biophysicalparameters of a biophysical model of the lung using the multipledisplacement fields of the lung tissue between different breathingphases of the lung and the corresponding sets of biometric parameters.In some embodiments, calculating the one or more biophysical parametersincludes calculating one or more derivatives of the displacement field(e.g., a curl, gradient, etc.). In some embodiments, the biophysicalparameters are biomechanical parameters (e.g., stress, strain, elasticmodulus, elastic limit, etc.). In some embodiments, the one or morebiophysical parameters define (3320) a physical relationship between thebiometric parameters associated with the different breathing phases ofthe lung and the multiple displacement fields of the lung tissue. Insome embodiments, the set of biometric parameters associated with arespective breathing phase includes (3322) a tidal volume and an airflowof the lung at the respective breathing phase and a cardiac phasecorresponding to the respective breathing phase of the lung. In someembodiments, the physical relationship between the biometric parametersassociated with the different breathing phases of the lung and themultiple displacement fields of the lung tissue is defined as follows:

−

₀ =T _(V)

₁ +A _(f)(

₂+

₃)+H _(c)

₄

The

₁ vector describes normal stress caused by tidal volume,

₂ describes normal stress caused by airflow,

₃ describes shear stress caused by airflow, and

₄ describes tissue motion introduced by heart motion, the displacement (

−

₀) of tissue at any point in a closed loop trajectory is expressed as asummation of the stress, strain, and perturbing heart motion vectorsscaled by the tidal volume (T_(v)), airflow (A_(f)), and cardiac phase(H_(c)) respectively.

In some embodiments, the different breathing phases of the lung include(3324) early exhalation, late exhalation, maximum exhalation, earlyinhalation, late inhalation, and maximum inhalation of a completebreathing cycle of the patient.

In some embodiments, the method further includes displaying a visualrepresentation of the biophysical parameters. For example, FIG. 30provides an example in which the biophysical parameter is the ratio of

₁ to (

₂+

₃). In some embodiments, displaying the visual representation includesdisplaying an image of the lung, wherein a color of a location withinthe image of the lung corresponds to the biophysical parameter (e.g., animage of the lung is displayed using a color map of the biophysicalparameter). Displaying such visual representation improves the x-rayimaging apparatus itself by increasing the accuracy of diagnoses. Forexample, it is much easier to see that the patient's left lung isdiseased in FIG. 30 than with conventional radiographs, as shown in FIG.29.

In some embodiments, the method further includes generating (3326)multiple medical image cubes corresponding to the different breathingphases of the lung from the multiple x-ray measurements corresponding tothe different breathing phases of the lung (e.g., as described withreference to FIGS. 21A-21B). In some embodiments, the multipledisplacement fields of lung tissue are extracted (3328) from themultiple medical image cubes corresponding to different breathing phasesof the lung further by delineating the lung tissue from a remainingportion of a first medical image cube through image segmentation and,for a respective voxel in the first medical image cube, determining adisplacement vector between the voxel in the first medical image cubeand a second medical image cube using intensity-based structure mappingbetween the first medical image cube and the second medical image cube.The multiple displacement fields of lung tissue are extracted from themultiple medical image cubes corresponding to different breathing phasesof the lung further by iteratively refining the displacement vectors ofdifferent voxels in the first medical image cube and their counterpartsin the second medical image cube.

In some embodiments, the method further comprises choosing (3330) one ormore of the multiple medical image cubes as reference medical imagecubes, determining a set of biometric parameters associated with eachreference medical image cube, selecting a set of biometric parametersbased on biometric measurements of the lung between two sets ofbiometric parameters associated with two reference medical image cubes,and simulating a medical image cube between the two reference medicalimage cubes by applying the set of biometric parameters based onbiometric measurements of the lung to the biophysical model.

It should be understood that the particular order in which theoperations in FIGS. 33A-33C have been described is merely an example andis not intended to indicate that the described order is the only orderin which the operations could be performed. One of ordinary skill in theart would recognize various ways to reorder the operations describedherein. Additionally, it should be noted that details of other processesdescribed herein with respect to other methods described herein are alsoapplicable in an analogous manner to method 3100 described above withrespect to FIGS. 32A-32B. Such process are described, for example, withreference to FIG. 2, FIG. 6, FIG. 8, FIG. 11, FIG. 13, FIG. 15, FIGS.21A-21B, FIG. 23, FIG. 25, FIG. 27, FIGS. 28A-28B, FIGS. 31A-31B, FIGS.32A-32B, and FIGS. 34A-34C. For brevity, these details are not repeatedhere.

FIGS. 34A-34C are flowcharts illustrating a method 3400 for generating a3D x-ray image cube movie from 2D x-ray images of a patient. In someembodiments, any or all of the operations described below can beperformed without human intervention (e.g., without intervention by atechnician). In some embodiments, method 3300 is performed by or usingany of the apparatuses described herein (e.g., the GREX imaging system100 shown in FIG. 1). Some operations of method 3400 are performed by acomputer system that includes one or more processors and memory storinginstructions which, when executed by the one or more processors, causethe one or more processors to perform the operations of method 3300.Some operations in method 3400 are, optionally, combined and/or theorder of some operations is, optionally, changed.

In some embodiments, one or more sensors are used (3402) for measuringbiometric signals of the patient as one or more sequences of timeseries, including one or more of a 3D spatial position localizer, abreathing phase sensor, and a cardiac phase sensor (e.g., as describedabove with reference to method 3100 and method 3200).

In some embodiments, the method further comprises identifying (3406) acardiac phase gating window using one or more cardiac phase sensormeasurements, predicting a breathing phase using one or more breathingphase sensor measurements, identifying a coincidence between the cardiacphase gating window and the predicted breathing phase for generating anx-ray imaging pulse, and tagging an x-ray image corresponding to thex-ray imaging pulse with the breathing phase, the cardiac phase, and 3Dspatial position localizer measurements (e.g., as described above withreference to method 3200).

In some embodiments, the 3D spatial position localizer is configured(3408) for measuring the patient's real-time body movement caused byrespiration and heartbeats and outputting them as time series (e.g., asdescribed above with reference to method 3100 and method 3200).

In some embodiments, the breathing phase sensor is configured (3410) formeasuring one or more physiologic metrics related to the patient'sbreathing, including a tidal volume and its first-order time derivative.For example, the rate of tidal volume changes over time or airflow.

In some embodiments, the cardiac phase sensor is configured (3412) formeasuring periodic and stationary electrical signal generated by thepatient's heart, with characteristic features that correspond to thecardiac phase.

In some embodiments, two distinct filters are used (3414) to removesignal drift and noise from biometric signals of the patient after beingsynchronized with an x-ray unit's clock.

In some embodiments, the biometric signals of the patient measured bythe one or more sensors are used (3416) for triggering an x-ray unit toacquire an x-ray image of the patient at a specific breathing andcardiac phase.

In some embodiments, the x-ray unit includes (3418) a clock. Thebiometric signals of the patient measured by the one or more sensors aresynchronized with the x-ray unit's clock and the respective values ofthe biometric signals are recorded to be associated with the acquiredx-ray image.

In some embodiments, the biometric signals of the patient are measured(3422) during a training window (e.g., a training period) beforecapturing any x-ray image of the patient and the biometric signals ofthe patient measured during the training window include multiplecomplete breathing cycles of the patient (e.g., as described above withreference to method 3100 and method 3200).

In some embodiments, multiple tidal volume percentiles within a completebreathing cycle are identified (3424) using the biometric signals of thepatient measured during the training window, each tidal volumepercentile corresponding to one of the different breathing phases.

In some embodiments, the biometric signals of the patient measuredduring the training window are used (3426) for building an optimizedbreathing prediction model for predicting a desired breathing phase atwhich an x-ray unit is triggered to capture an x-ray image of thepatient.

In some embodiments, the optimized breathing prediction model is (3428)based on an autoregressive integrated moving average (ARIMA) model.

In some embodiments, the desired breathing phase for capturing the x-rayimage of the patient is configured (3430) to coincide with a cardiacgating window during which heart induced lung motion is changing slowly.

In some embodiments, the cardiac gating window is chosen (3432) based onlocations of T wave and P wave in an electrocardiogram (ECG) signal suchthat the heart induced lung motion is changing slowly.

The method includes converting (3434) first multiple sets of x-rayimages of a lung captured at different projection angles into secondmultiple sets of x-ray images of the lung corresponding to differentbreathing phases.

In some embodiments, converting first multiple sets of x-ray images of alung captured at different projection angles into second multiple setsof x-ray images of the lung corresponding to different breathing phasesfurther comprises (3436) capturing the first multiple sets of x-rayimages of the lung at different projection angles. Each set of the firstmultiple sets of x-ray images corresponds to the different breathingphases of the lung at a particular projection angle. In someembodiments, converting first multiple sets of x-ray images of a lungcaptured at different projection angles into second multiple sets ofx-ray images of the lung corresponding to different breathing phasesfurther comprises re-organizing the first multiple sets of x-ray imagesof the lung by their associated breathing phases into the secondmultiple sets of x-ray images of the lung. Each set of the secondmultiple sets of x-ray images corresponds to a respective breathingphase of the lung.

In some embodiments, the x-ray images within any particular set are(3438) geometrically resolved and temporally independent.

In some embodiments, the different breathing phases of the lungcorrespond (3440) to different tidal volume percentiles of the lung'smovement.

In some embodiments, the different breathing phases of the lung include(3442) early exhalation, late exhalation, maximum exhalation, earlyinhalation, late inhalation, and maximum inhalation of a completebreathing cycle of the patient.

In some embodiments, n the multiple x-ray images of the lung captured atdifferent projection angles all correspond (3444) to the same breathingphase.

In some embodiments, the different breathing phases of the lung at aparticular projection angle are collected (3446) from at least twobreathing cycles.

The method includes generating (3448) a static image cube from each setof the second multiple sets of x-ray images at a respective breathingphase using back projection.

The method includes combining (3450) the static image cubescorresponding to the different breathing phases of the lung into a 3Dx-ray image cube movie through temporal interpolation.

It should be understood that the particular order in which theoperations in FIGS. 34A-34C have been described is merely an example andis not intended to indicate that the described order is the only orderin which the operations could be performed. One of ordinary skill in theart would recognize various ways to reorder the operations describedherein. Additionally, it should be noted that details of other processesdescribed herein with respect to other methods described herein are alsoapplicable in an analogous manner to method 3100 described above withrespect to FIGS. 34A-34C. Such process are described, for example, withreference to FIG. 2, FIG. 6, FIG. 8, FIG. 11, FIG. 13, FIG. 15, FIGS.21A-21B, FIG. 23, FIG. 25, FIG. 27, FIGS. 28A-28B, FIGS. 31A-31B, FIGS.32A-32B, and FIGS. 33A-33C. For brevity, these details are not repeatedhere.

FIG. 35 depicts an exemplary patient positioning fixture (PPF) 3501(e.g., a rotatable chair) for supporting a patient 3502 in accordancewith some embodiments. In some embodiments, PPF 3501 rotates (e.g.,along rotation 3503) to position the patient 2502 at a plurality ofangles (e.g., orientations) with respect to radiation source 3504 (e.g.,an x-ray imaging system or a radiation therapy system). For example, thePPF moves in such a way as to move the patient to the desired position(e.g., the patient does not need to move independently) so that theradiation device 3504 is enabled to capture x-ray images of the patientat various angles. In some embodiments, the patient 3502 rotates (e.g.,along rotation 3502) to achieve the plurality of angles without rotatingthe PPF 3501. In some embodiments, the PPF 3501 and/or the patient 3205are automatically rotated and/or moved (e.g., using a motor) to adesired position. In some embodiments, a technician rotates and/or movespatient 3502. In some embodiments, a flat panel detector unit 3505 ispositioned behind the patient relative to the radiation device 3504.

In some embodiments, one or more cameras 3506-1 to 3506-m are used todetect objects within a predefined area (e.g., a room) surrounding PPF3501. For example, the camera(s) 3506 capture if an object will collidewith the PPF 3501 as the PPF 3501 is moved around (and rotated within)the predefined area. In some implementations, a method for collisionavoidance between PPF 3501 (and patient 3502) is provided.

In some embodiments, one or more 3D imaging sensors (e.g., LIDAR sensorsor structured light sensors) are used to geometrically monitor thebreathing of the patient 3502, as described with reference to method3100.

FIG. 36 depicts an exemplary biological event monitoring process (BEMP)card 3600. BEMP card 3600 includes a programmable analog filter; aprogrammable analog to digital converter (ADC)/digital signal processor(DSP) 3605; and a zero instruction set computer (ZISC) processor 3606.The BEMP card 3600 receives an analog input signal 3602, which comprisesa biometric signal of the patient. In some embodiments, the analog input3602 comprises an ECG signal. In some embodiments, the analog input is a3-lead ECG signal or a 12-lead ECG signal. The ZISC processor 3606detects predefined patterns in the analog input in real-time. Forexample, the ZISC processor(s) 3606 detects an R wave in an ECG signalto predict when the next quiescent period of the patient's cardiac cyclewill be (e.g., in the TP interval). In some embodiments, the ZISCprocessor 3606 outputs the ZISC 4 bit weighted output that can be usedto trigger a radiation source (e.g., an x-ray imaging system or aradiation therapy system). In some embodiments, a clock signal 3603 forthe BEMP card 3600 is provided from an external source, such as theradiation source, so that the BEMP card 3600 can be synchronized to theradiation source.

The computational techniques discussed throughout the post-processingsoftware 106 section are computationally resource-intensive. Manycommunity hospitals and small clinics do not have access to the computerhardware necessary to create the movies, calculate the biomechanicalmodels, and present results with a fast, smooth experience for theend-user. The post-processing software 106's functions are performed inthe cloud so that the end-user can have access to the post-processingsoftware 106's powerful visualization tools on a treatment console,office desktop, or work laptop.

Reference throughout this specification to “an embodiment,” “someembodiments,” “one embodiment”, “another example,” “an example,” “aspecific example,” or “some examples,” means that a particular feature,structure, material, or characteristic described in connection to theembodiment or example is included in at least one embodiment or exampleof the present disclosure. Thus, the appearances of the phrases such as“in some embodiments,” “in one embodiment”, “in an embodiment”, “inanother example,” “in an example,” “in a specific example,” or “in someexamples,” in various places throughout this specification are notnecessarily referring to the same embodiment or example of the presentdisclosure. Furthermore, the particular features, structures, materials,or characteristics may be combined in any suitable manner in one or moreembodiments or examples.

Although explanatory embodiments have been shown and described, it wouldbe appreciated by those skilled in the art that the above embodimentscannot be construed to limit the present disclosure, and changes,alternatives, and modifications can be made in the embodiments withoutdeparting from spirit, principles and scope of the present disclosure.

What is claimed is:
 1. A method, comprising: positioning a patient at afirst orientation relative to an x-ray imaging apparatus; obtaining avolumetric measurement of the patient's breathing; while obtaining thevolumetric measurement of the patient's breathing: determining, based onthe volumetric measurement of the patient's breathing, a breathing phaseof the patient; gating the x-ray imaging apparatus, based on thepatient's breathing phase as determined from the volumetric measurement,to obtain multiple x-ray measurements corresponding to differentbreathing phases of the lung; and extracting multiple displacementfields of lung tissue from the multiple x-ray measurements correspondingto different breathing phases of the lung, wherein each displacementfield represents movement of the lung tissue from a first breathingphase to a second breathing phase and each breathing phase has acorresponding set of biometric parameters.
 2. The method of claim 1,wherein the gating of the x-ray imaging apparatus is based on adetermination that the breathing phase of the patient matches arespective breathing phase of a plurality of predefined breathingphases.
 3. The method of claim 1, including calculating one or morebiophysical parameters of a biophysical model of the lung using themultiple displacement fields of the lung tissue between differentbreathing phases of the lung and the corresponding sets of biometricparameters.
 4. The method of claim 1, wherein the gating of the x-rayimaging apparatus is based on a determination that the breathing phaseof the patient matches any of the plurality of predefined breathingphases.
 5. The method of claim 1, wherein x-ray projections of thepatient's lung are not obtained except when the breathing phase of thepatient, as determined by the volumetric measurement of the patient'sbreathing, matches one of the plurality of predefined breathing phases.6. The method of claim 1, wherein the plurality of predefined breathingphases includes an early exhalation phase and a late exhalation phase.7. The method of claim 1, wherein: the multiple x-ray measurements arefirst multiple x-rays measurements, and the method further includes:repositioning the patient to a second orientation relative to the x-rayimaging apparatus; obtaining second multiple x-ray measurementscorresponding to the different breathing phases of the lung, including,while obtaining the volumetric measurement of the patient's breathingwhile the patient is positioned at the second orientation relative tothe x-ray imaging apparatus: continuing to determine, based on thevolumetric measurement of the patient's breathing, a breathing phase ofthe patient; and in accordance with a determination that the breathingphase of the patient matches the respective breathing phase, gating thex-ray imaging apparatus to produce a second x-ray projection of thepatient's lung; and generating a static image cube, corresponding to therespective breathing phase, using the first multiple x-ray measurementsand the second multiple x-ray measurements.
 8. The method of claim 7,wherein the static image cube, corresponding to the respective breathingphase, is generated using less than ten x-ray projections obtained fromvarious angles at the respective breathing phase.
 9. The method of claim1, wherein the volumetric measurement of the patient's breathingincludes a measurement of the patient's chest rise.
 10. The method ofclaim 1, wherein the volumetric measurement of the patient's breathingis obtained using one or more volumetric breathing phase sensors of thegroup consisting of: a three-dimensional (3D) scanner, a spirometer, andan abdominal belt.
 11. The method of claim 1, further including creatinga point cloud of a surface of the patient's chest, wherein thevolumetric measurement of the patient's breathing is determined from thepoint cloud of the surface of the patient's chest.
 12. The method ofclaim 11, wherein the point cloud of the surface of the patient's chestis obtained using a 3D imaging technique to measure one or morepositions of the patient's chest.
 13. The method of claim 12, furtherincluding: identifying one or more anatomical landmarks on the surfaceof the patient's chest using the point cloud of the surface of thepatient's chest; and inferring a location of one or more internalanatomical landmarks within the patient's chest from the point cloud ofthe surface of the patient's chest.
 14. The method of claim 1, wherein:the breathing phase of the patient is a future breathing phase; anddetermining, based on the volumetric measurement of the patient'sbreathing, a breathing phase of the patient includes forecasting thefuture breathing phase from one or more current and/or past breathingphases.
 15. A system, comprising: an x-ray apparatus; one or moreprocessors; and memory storing instructions which, when executed by theone or more processors, cause the one or more processors to perform aset of operations, including: positioning patient at a first orientationrelative to an x-ray imaging apparatus; obtaining a volumetricmeasurement of the patient's breathing; while obtaining the volumetricmeasurement of the patient's breathing: determining, based on thevolumetric measurement of the patient's breathing, a breathing phase ofthe patient; gating the x-ray imaging apparatus, based on the patient'sbreathing phase as determined from the volumetric measurement, to obtainmultiple x-ray measurements corresponding to different breathing phasesof the lung; and extracting multiple displacement fields of lung tissuefrom the multiple x-ray measurements corresponding to differentbreathing phases of the lung, wherein each displacement field representsmovement of the lung tissue from a first breathing phase to a secondbreathing phase and each breathing phase has a corresponding set ofbiometric parameters.
 16. The system of claim 15, wherein the gating ofthe x-ray imaging apparatus is based on a determination that thebreathing phase of the patient matches a respective breathing phase of aplurality of predefined breathing phases, gating the x-ray imagingapparatus to produce an x-ray projection of the patient's lung.
 17. Thesystem of claim 15, wherein the set of operations further includescalculating one or more biophysical parameters of a biophysical model ofthe lung using the multiple displacement fields of the lung tissuebetween different breathing phases of the lung and the correspondingsets of biometric parameters.
 18. The system of claim 15, wherein thegating of the x-ray imaging apparatus is based on a determination thatthe breathing phase of the patient matches any of the plurality ofpredefined breathing phases.
 19. The system of claim 15, wherein x-rayprojections of the patient's lung are not obtained except when thebreathing phase of the patient, as determined by the volumetricmeasurement of the patient's breathing, matches one of the plurality ofpredefined breathing phases.
 20. The system of claim 15, wherein theplurality of predefined breathing phases includes an early exhalationphase and a late exhalation phase.
 21. The system of claim 15, wherein:the multiple x-ray measurements are first multiple x-rays measurements,and the set of operations further includes further includes:repositioning the patient to a second orientation relative to the x-rayimaging apparatus; obtaining second multiple x-ray measurementscorresponding to the different breathing phases of the lung, including,while obtaining the volumetric measurement of the patient's breathingwhile the patient is positioned at the second orientation relative tothe x-ray imaging apparatus: continuing to determine, based on thevolumetric measurement of the patient's breathing, a breathing phase ofthe patient; and in accordance with a determination that the breathingphase of the patient matches the respective breathing phase, gating thex-ray imaging apparatus to produce a second x-ray projection of thepatient's lung; and generating a static image cube, corresponding to therespective breathing phase, using the first multiple x-ray measurementsand the second multiple x-ray measurements.
 22. The system of claim 21,wherein the static image cube, corresponding to the respective breathingphase, is generated using less than ten x-ray projections obtained fromvarious angles at the respective breathing phase.
 23. The system ofclaim 15, wherein the volumetric measurement of the patient's breathingincludes a measurement of the patient's chest rise.
 24. The system ofclaim 15, wherein the volumetric measurement of the patient's breathingis obtained using one or more volumetric breathing phase sensors of thegroup consisting of: a three-dimensional (3D) scanner, a spirometer, andan abdominal belt.
 25. The system of claim 15, wherein the set ofoperations further includes creating a point cloud of a surface of thepatient's chest, wherein the volumetric measurement of the patient'sbreathing is determined from the point cloud of the surface of thepatient's chest.
 26. The system of claim 25, wherein the point cloud ofthe surface of the patient's chest is obtained using a 3D imagingtechnique to measure one or more positions of the patient's chest. 27.The system of claim 26, wherein the set of operations further includes:identifying one or more anatomical landmarks on the surface of thepatient's chest using the point cloud of the surface of the patient'schest; and inferring a location of one or more internal anatomicallandmarks within the patient's chest from the point cloud of the surfaceof the patient's chest.
 28. The system of claim 15, wherein: thebreathing phase of the patient is a future breathing phase; anddetermining, based on the volumetric measurement of the patient'sbreathing, a breathing phase of the patient includes forecasting thefuture breathing phase from one or more current and/or past breathingphases.
 29. A non-transitory computer-readable storage medium storinginstructions, which, when executed by a system that includes an x-rayapparatus and one or more processors, cause the one or more processorsto perform a set of operations, including: positioning the patient at afirst orientation relative to an x-ray imaging apparatus; obtaining avolumetric measurement of the patient's breathing; while obtaining thevolumetric measurement of the patient's breathing: determining, based onthe volumetric measurement of the patient's breathing, a breathing phaseof the patient; gating the x-ray imaging apparatus, based on thepatient's breathing phase as determined from the volumetric measurement,to obtain multiple x-ray measurements corresponding to differentbreathing phases of the lung; and extracting multiple displacementfields of lung tissue from the multiple x-ray measurements correspondingto different breathing phases of the lung, wherein each displacementfield represents movement of the lung tissue from a first breathingphase to a second breathing phase and each breathing phase has acorresponding set of biometric parameters.